Use this form to request approval for gender affirmation coverage.

Step 1: Complete a form.

Download the form and print it, or fill it out in Adobe Reader XI or higherOpens a new website in a new windowOpens a new website in a new window 

Step 2: Ask your healthcare provider to complete the physician information section.

Step 3: Submit your request for approval.

You’ll find instructions on how to submit your claim on the form itself.