Coverage for Sex-Trait Modification Treatment (FEHBP exception process)
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Defines changes to coverage of sex-trait modification treatments under the FEHBP for CareFirst BlueCross BlueShield Advantage Dualprime members, including an exception process for individuals who are mid-treatment as of Jan 1, 2026.
OPM directed that sex-trait modification treatments for diagnosed gender dysphoria will no longer be covered under FEHBP starting Jan. 1, 2026, except via a limited exception process for eligible mid-treatment individuals 19 years or older.
Defines 'mid-treatment' as having begun HRT, hormone blockers, or approved/started surgical modification before Jan. 1, 2026.
Establishes operational exception process and submission routes (provider portal precertification for surgery; mail or member portal upload for hormone/other services) and contact points including CVS for authorization confirmation.
Specifies eligibility limits: members under 19 and members who switch plans during open enrollment are not eligible for exceptions.
Limits exceptions to the treatment stage the member was in as of Dec. 31, 2025, and caps coverage duration for hormone authorizations to either the authorization end date or Dec. 31, 2026, whichever comes first.
Maintenance services (e.g., hair removal, voice therapy) are not eligible for exceptions; reconstructive surgery post-surgical modification may be covered if medically necessary.
Coverage Criteria and Scope
Exception criteria
Covered only via a limited exception process for eligible mid‑treatment members — exceptions are restricted by age, treatment stage as of Dec. 31, 2025, and duration limits.
Per OPM direction
Members who switch plans during open enrollment are not eligible.
If current hormone authorization ends before Jan. 1, 2026, member is not eligible for an exception.
Confirm current authorization status by calling CVS at 800-241-3371 before submitting an exception request.
Precertification is required for surgical exceptions via the CareFirst Provider Portal or required form.
Services related to approved treatment exceptions will otherwise be covered in conjunction with the 2026 CareFirst FEHBP Brochure benefits.
Starting Jan. 1, 2026, the Office of Personnel Management (OPM) has directed that sex-trait modification treatments for diagnosed gender dysphoria will no longer be routinely covered under FEHBP. Coverage may continue only through a limited exception process for eligible individuals; absent an approved exception, these services are not covered.
Maintenance services such as hair removal and voice therapy are explicitly not eligible for an exception and therefore will not be covered. Reconstructive surgery to the surgical site performed after a covered surgical modification may be covered if it is medically necessary and falls within the benefits outlined for approved treatment exceptions.
Eligibility Details & Coding Notes
Authorization, Submission, and Denial Risks
Precertification required for surgical exceptions; confirm hormone authorizations
Providers must submit a Precertification Request for Authorization of Services through the CareFirst Provider Portal for surgical treatment exceptions; for hormone-treatment authorization confirmation, contact CVS at 800-241-3371 before submitting an exception request.
- Use the CareFirst Provider Portal to submit precertification for surgical exceptions.
- Call CVS at 800-241-3371 to confirm current authorization status for hormone treatment prior to exception submission.
Exceptions limited to treatment stage on Dec. 31, 2025; hormone duration capped
Exceptions are limited to the single treatment stage the member was in as of Dec. 31, 2025; an exception cannot be used to begin a new stage. Hormone authorizations granted under an exception may continue only until the authorization expires or Dec. 31, 2026, whichever comes first.
- Exceptions apply only to the stage active on Dec. 31, 2025 (psychological counseling; hormone treatment; or surgical modification).
- If a hormone authorization extends beyond Dec. 31, 2025, exception coverage ends at the authorization end date or Dec. 31, 2026, whichever is earlier.
Use CareFirst Provider Portal for surgical precertification; mail or member portal for hormone/other requests
For surgical exceptions, submit a Precertification Request for Authorization of Services through the CareFirst Provider Portal or complete the required form; for hormone or other services, submit the exception request by mail to the Mail Administrator or upload via the CareFirst member portal.
- Surgical precertification: CareFirst Provider Portal (Precertification Request for Authorization of Services) or required form.
- Hormone/other services: Mail to Mail Administrator, P.O. Box 14114, Lexington, KY 40512-4114, or upload via the CareFirst member portal (My Account).
- If unsure about qualification or process, contact Member Services for assistance.
Eligibility-based denials for under-19, plan switches, or new-stage treatments
Members under age 19, members who switch health plans during open enrollment, and treatments that would begin a new stage after Dec. 31, 2025 are not eligible for exceptions and may be denied.
- Do not submit exception requests for members under 19.
- Members who switch plans during open enrollment are ineligible for exceptions.
- Exceptions cannot be used to start a new treatment stage after Dec. 31, 2025; such requests risk denial.
Policy Background
The Office of Personnel Management directed removal of routine FEHBP coverage for sex-trait modification treatments effective Jan. 1, 2026. OPM’s direction creates a limited exception pathway that applies only to members who are 19 years or older and who were mid-treatment (having begun hormone replacement therapy, hormone blockers, or an approved/started surgical modification) before Jan. 1, 2026. Mental health services related to gender dysphoria remain covered and do not require an exception. The exception process is stage-limited (psychological counseling, hormone treatment, surgical modification) and exceptions apply only to the stage active as of Dec. 31, 2025; maintenance services are excluded and eligibility rules (for example, members under 19 or those who change plans during open enrollment) will result in denial of exception requests.
Key Definitions
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