1.0 DESCRIPTION
GD is a condition where a person
experiences clinically significant distress, or impairment in social,
occupational, or other important area of functioning, of at least
six months duration, because of a marked incongruence between the
sex assigned, usually at birth (i.e., natal sex) and their experienced/expressed
gender identity. The clinical definition is provided in the Diagnostic
and Statistical Manual of Mental Disorders (DSM), Fifth Edition
(May, 2013). Diagnosis is to be made using the most current edition
of the DSM.
2.0 POLICYMedically or psychologically
necessary and appropriate medical care (as defined in 32
CFR 199.2), including non-surgical
treatments for GD, are covered when provide by a TRICARE-authorized
provider.
1.1 Mental Health Treatment
1.1.1 Psychotherapy for
theMental health care services for the
diagnosis and treatment of GD and psychotherapy
for beneficiaries pursuing transition are covered for
all beneficiaries.
1.1.2 Consistent with mental health
treatment for other diagnoses, outpatient, office-based, mental
health visits shall not require a referral or preauthorization.
1.1.3 Treatment team conferences (Common
Procedural Terminology (CPT) codes 99366, 99367, and 99368) are
covered.
Note: Active Duty Service Members
(ADSMs) require Military Medical Treatment Facility (MTF) referral/authorization
or Specified Authorized Staff (SAS) preauthorization prior to receiving
non-emergency health care services (other than primary health care
for members enrolled in TRICARE Prime Remote (TPR)) in the private
sector. The contractor shall comply with the provisions of the TRICARE
Operations Manual (TOM),
Chapters 16 and
17 when
processing requests for ADSMs.
1.2 Endocrine Treatment
Gender-affirming
hormone therapy, also known as crossCross-sex
hormone treatment, is covered for adult
or adolescent beneficiaries ages 19 and
older when all of the following criteria are met:
• The beneficiary meets the eligibility
criteria outlined in the most current version of the Endocrine Society Clinical
Practice Guidelines for Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent
Persons.
• The beneficiary has no contraindications
to gender-affirming hormone therapy.
Note: Endocrine treatment includes pubertal
suppression.
2.0 EXCLUSIONS
2.1 Surgical procedures
and all services and supplies related thereto for the treatment
of GD for all beneficiaries (10 USC 1079). All services
and supplies related to surgical treatment for GD (i.e., gender-affirming surgical
procedures) that attempt to transform
an individual’s physical appearance to align with an identity that differs
from his or her sex or that attempt to alter or remove an individual’s
sexual organs to minimize or destroy their natural biological functions,
including, but not limited to, mastectomy, oophorectomy, and orchiectomy. ADSMs
may obtain the surgical treatment for GD with a Supplemental Health
Care Program (SHCP) waiver approved by the Defense Health Agency
(DHA) Director or the delegated authority.
3.3 Endocrine treatment
of prepubertal children prior to Tanner Stage 2.
2.3 Voice therapy by a speech
-language
pathologist
(SLP) to transform speech patterns
of the affirmed gender. See
Chapter 7, Section 7.1.
2.4 Effective December 23,
2024, for beneficiaries under the age of 18, and March 13, 2025,
for beneficiaries who are 18 years of age, the following services
are excluded:2.4.1 Puberty blockers including
Gonadotropin-Releasing Hormone (GnRH) agonists and other interventions,
to delay the onset or progression of normally timed puberty in an
individual who does not identify as his or her sex;
2.4.2 The use of sex-hormones,
such as androgen blockers, estrogen, progesterone, or testosterone,
to align an individual’s physical appearance with an identity that
differs from his or her sex.
