Getting Insurance Coverage with Specific Plan Exclusion

[vanderpn]

So I created this thread a while ago, but it's been so long that I thought I would create a new one.

As I described previously, my family's insurance changed to Cigna this year. My dad's company's HR finally made the plan documents available, and they contain the following under the exclusions section:

transsexual surgery including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery.

I know from other threads that I've seen some of you have similar statements in your plans yet have gotten coverage. Right now, I'm specifically concerned about the peripheral costs of HRT, such as doctor's visits and lab work. I know that getting coverage for the hormones themselves might be harder with an exclusion like this, so I'm not as worried about that.

So, could anyone in a similar situation share how they got coverage? What did you discuss with your doctor about insurance? Did your doctor describe to you how they were phrasing the claim that they were submitting? Anything else that you think might be helpful to know?

Thanks so much for the help.

EDIT: Mods, I realized that this might fit better under Legal Matters, although my question is specifically about HRT coverage. Please feel free to move this at your own discretion. Thanks.

[NikkiB51]

My CIGNA plan has the same exact language and my state has passed legislation saying it cannot be excluded.  I called CIGNA and they said my plan was self-funded and did not have to follow the law.  A loophole, I know, but it exists nonetheless.  I have not specifically tried to appeal any denial of claims, so I don't know if that would work in this case.  I have found doctor's to be "creative" in their coding of treatment and Target, Wal-Mart and CVS have $4 generic prescriptions which include estradiol valerate, spironolactone and finasteride (pill form, not injectable) although injectable is available for around 80 to 100 dollars, if you go that route (approximately 160 -200 per month on "standard" dosage).

Out of pocket is my only option when specific exclusions apply.  Doesn't hurt to appeal, you just have to pay out of pocket, if it is denied.

[Devlyn]

My wardrobe change cost a heck of a lot more than the bloodwork ($1,100) and monthly HRT bill ($94). I really wouldn't put tons of stress into worrying if they're covered by insurance or not. 

Hugs, Devlyn

[FTMax]

You could appeal to your dad's company to remove the exclusion. I am not sure what the process is for that, but I know some people have been successful going that route. I'm not sure how much of a headache it is, but if you're planning on surgeries down the road I would definitely look into it.

A good doctor can get lab work, visits, and possibly even your hormones covered. When I first started seeing my doctor, she coded it as something like a non-specific endocrine disorder. Now that I'm male on insurance, she codes it as something relating to low testosterone (I think testicular dysfunction ). When I've had to get very expensive sets of labs done for surgical clearances she codes it as all kinds of things to get it covered like fatigue, chronic pain, at-risk sexual behavior. Whatever it takes to get it paid for!

I mentioned to mine in the beginning that I was worried about getting everything covered and that I could not afford to pay full price for any of it. I think going to a community health clinic helped, as they're really sympathetic to low income folks. If the Planned Parenthood locations in your area offer HRT, they may be the best option.

[vanderpn]

Thanks for the info from everyone so far.

The big problem is that I still live with and am dependent upon my parents. I'm on the autism spectrum and struggle with a lot of mental health issues, so it took me six years to get through college. I finally just now graduated, so I don't have a job yet; I had to quit my most recent internship/part-time job because my depression got so bad.

We're by no means poor, and I'm sure we could make it work by being more thrifty than we currently have to be. So it's more about justifying the costs to my parents if we would have to pay out of pocket. They've accepted me well, but they're not so keen on forking out more money, especially since I'm so dependent on them for everything else.

I've tried to explain to them that it's just as vital to my health as my antidepressants, therapy appointments, etc., but they haven't seemed to understand that. sigh

I have considered appealing the company. I've interned there several times and have had pretty good experiences; I even worked with the HR employee who deals with health benefits. I'm just not sure where to start. If anyone who has appealed their company is reading this, could you comment on how you went about that?

Wow, I apologize for the long post. I can tell I'm stressed about this because last night I had a semi-realistic dream about successfully appealing the company and coming out to my previous coworkers. Who knows, maybe I'm psychic?!  Here's hoping, anyway.