Western Health Advantage Policies

Contraception Exception Process

Contraception Benefits – Covered Services

WHA covers a range of contraceptive and/or family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the Health Resources and Services Administration (HRSA) list. This includes:

• Voluntary female sterilization
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process. For example, services for voluntary female sterilization surgery not performed in connection with another procedure, such as caesarean delivery or abortion, requires prior authorization from your Primary Care Physician's affiliated medical group or some cases directly from WHA. The prior authorization may be submitted directly to your medical group for review or you or your authorized representative may ask for a coverage request by calling WHA’s Member Services Department, at 888-563-2250.

Prescription Medications

Contraceptive coverage is available at no cost to FEHB members. WHA contracted physicians can prescribe the appropriate level of medically necessary medication to our FEHB members without unnecessary approvals. The contraceptive benefits include at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). 

Any contraceptive that is not already available without cost sharing on the formulary can be accessed through a prior authorization process which your provider can submit electronically through CoverMyMeds or filling out the “Prescription Drug Prior Authorization or Step Therapy Exception Request Form” here. All prior authorization requests will be reviewed and responded to within 24 hours of receipt of sufficient information necessary to make a coverage determination.

Gender Affirming Care and Services

WHA covers certain transgender and services related members with a diagnosis of gender dysphoria (GD). This includes a range of transgender services, including certain surgeries, when deemed medically necessary, as well as non-surgical services that are also deemed medically necessary.

Medical necessity criteria currently used to make coverage decisions for WHA members seeking transgender services are based in part on the Standards of Care (SOC) Version 8, developed by World Professional Associations for Transgender Health (WPATH). WHA aligns with WPATH SOC Version 8 with emphasis on the importance of respecting a member’s autonomy and reducing barriers of care.

WHA covers a range of gender-affirming surgeries in accordance with WPATH SOC 8 recommendations, including but not limited to chest (top) surgery, genital (bottom) surgery, facial feminization surgery, and vocal surgery. The type of surgery to be covered is determined based on the patient's clinical assessment and goals, as per SOC 8. When the clinical assessment and patient goals align with prevailing SOC guidelines, the guidelines will be followed.

Transgender services are numerous and can range from hormonal treatment and behavioral health therapy, to life-changing sexual transformation surgery. Adolescents under 18 years of age may be eligible with parental or legal guardian consent in accordance with WPATH SOC 8.

Therapeutic Options (include but are not limited to)

• Changes is expression or role, such as living part-time or full-time for a certain period of time in the gender with which the member identifies
• Psychotherapy
• Hormone therapy; and/or
• Gender-confirming surgery

Non-Surgical Services

• Behavioral health services
• Hormone therapy

Common Gender-Confirming Surgical Procedures
Male to Female (MTF)

• Orchiectomy (removal of testicles)
• Penectomy (removal of penis)
• Vaginoplasty (creation of vagina)
• Clitoroplasty (creation of clitoris)
• Labiaplasty (creation of labia)

Female to Male (FTM)

• Mastectomy with chest reconstruction (removal of breast, and nipple tattooing)
• Reduction mammoplasty (reduction of breast size)
• Hysterectomy (removal of uterus)
• Salpingo-oophorectomy (removal of fallopian tubes and ovaries)
• Vaginectomy (removal of vagina)
• Metoidioplasty (creation of micro-penis, using the clitoris tissue)
• Phalloplasty (skin graft is used to create a penis, with or without urethra)
• Penile implant 
• Urethroplasty (creation of urethra within the penis)
• Scrotoplasty (creation of scrotum)
• Placement of a testicular prosthesis/implants (the labia majora is dissected forming cavities allowing for implantation of artificial testes)

Note:  Gender-specific preventive screenings/services may be medically necessary for transgender persons appropriate to their anatomy (ex: breast cancer screening for FTM individual who has not had a mastectomy or prostate cancer screening for MTF individual who has not had a penectomy).

Infertility Services

As a WHA member, you have infertility benefits and services covered under your plan.  However, services are based on medical necessity for the treatment of infertility, and require prior authorization. 

“Infertility” is defined as a condition of being infertile. A member is considered infertile if there is a presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility, or the member is unable to conceive a pregnancy or to carry a pregnancy to a live birth after one (1) year of regular unprotected intercourse, or if the member is over age 35 years, after 6 months of regular unprotected intercourse. A member not having regular unprotected intercourse may be considered infertile if conception does not occur after at least 12 cycles of supervised artificial/donor insemination (6 cycles for members 35 years or older).

Diagnosis and treatment of infertility, up to 3 cycles, specific to the following:

• Artificial insemination
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Fertility drugs (include drugs for IVF)
• Gamete Intra-Fallopian Transfer (GIFT) or In Vitro Fertilization (IVF)
• Covered services included consultations, examinations, diagnostic services performed in a physician’s office or a facility, and medications for treatment of infertility. 

To learn more, you may click on the Infertility F Benefit. The summary also provides copayment information as well as exclusions and limitations.

Family and Diversity Support Benefit

In addition to Infertility Services, WHA also offers Family and Diversity (FamDiv) Support Benefit. This is a pregnancy support (with no exclusion of gender or relationship status), and without the diagnosis of infertility. It also covers pre-implantation genetic testing, supporting members with rare and life-threatening genetic conditions.

The FamDiv also requires prior authorization and covers up to 3 cycles of artificial insemination (AI). The Family and Diversity (FamDiv) Support Benefit summary also provides copayment information as well as exclusions and limitationas.

Note: Members an access AI benefits under WHA or FamDiv but cannot combine the WHA (Infertility) and FamDiv benefits.

Maternal Health

WHA offers the Maven Maternity program to our FEHB members. This is an on-demand virtual support program that provides comprehensive support through pregnancy, postpartum, and potential miscarriage. Video chat or message with any of Maven’s maternity coaches anytime, anywhere. This includes the following:

•    Prenatal and Postpartum Care, including information on Postpartum depression
•    One-on-One Care Engagement with a therapist, online assessments, videos, and resource guides for postpartum depression

You can learn more about Maven here. 

We also provide additional resources and information for your pregnancy, Healthy Pregnancy.

Obesity Management

Obesity counseling, screening and referral for those persons at or above the U.S. Preventive Services Task Force (USPSTF) obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider

With prior authorization approval, members who meet specified medical criteria and who demonstrate a documented readiness to make nutrition and lifestyle changes, may take advantage of nutrition and dietary counseling with a WHA network nutritionist or registered dietician in these areas of focus:

Obesity 

• Adults with a BMI greater than 25
• Adults with BMI greater than 25 and an obesity-related condition including but not limited to hypertension, hyperlipidemia, impaired fasting glucose, chronic back pain, knee osteoarthritis, fatty liver disease, polycystic ovary syndrome, infertility, cancer, gout, pseudotumor cerebri, gallbladder disease, obstructive sleep apnea, obstructive lung disease, lymphedema, and/or acid reflux

Eating Disorders

• Adults and children diagnosed with eating-related disorders (e.g. anorexia or bulimia)
• Documentation of patient under the ongoing care of behavioral health provider

Malnourishment and Weight Loss

• Adults and children with weight loss greater than or equal to 20% in the prior 12-month period due to medical conditions other than eating disorder related
• Documentation of specialist care as appropriate

You can find more information regarding the Nutrition Counseling benefits here.

Bariatric Surgery

We cover diagnosis and treatment of morbid obesity and considers surgical procedures medically appropriate when all of the general criteria, along with the criteria specific to the procedures are met and prior authorization is approved: 

Criteria for Adults 18 years of age or older:

• BMI of greater than 35 or higher (body mass index); OR
• BMI between 30 and 34.9 and at least one of the following documented high-risk comorbidities or clinically serious condition related to obesity, included but not limited to: 
  •  Severe uncontrolled type 2 diabetes mellitus
  • Obesity hypoventilation
  • Significant obstructive sleep apnea
  • Nonalcoholic fatty liver disease
  • Pseudotumor cerebri
  • Polycystic ovary syndrome
  • Severe lower extremity osteoarthritis
  • Severe chronic obstructive pulmonary disease
  • Significant asthma
  • Uncontrolled hypertension
  • Treatment-resistant hypertension
  • Congestive heart failure
  • Severe active coronary disease
• Adequate (6 months) healthcare provider supervised trial of non-operative weight loss in the 12 months immediately preceding the surgery request. The program should incorporate nutritional counseling and appropriate regular physical activity. Examples are: enrollment In Weight Watchers, Jenny Craig or work with a personal trainer at a gym alongside documented periodic follow-up visits with a dietician, physician, advanced care practitioner or rehab therapist. 
• Psychological Evaluation in the 3 months preceding date of request

Additional Information

Member is a candidate for bariatric surgery, as indicated by ALL of the following:

• Tried and failed to achieve and maintain sufficient weight loss with nonsurgical treatment
• Correctable cause for obesity not identified (e.g. hypothyroidism, Cushing syndrome)
• Current substance abuse not identified
• Not currently pregnant and no planned pregnancy within 18 months of surgery
• Expectation that member has ability to adhere to postoperative care requirements (e.g. judged to be committed, and willing to participate and adhere to postoperative instructions)
• No current untreated or uncontrolled eating disorder
• No serious untreated or uncontrolled medical, psychiatric, psychosocial, or cognitive condition that would interfere with adherence to postoperative instructions and self-care
• Receiving treatment in multidisciplinary program that can provide ALL of the following:
  • Preoperative medical consultation
  • Preoperative mental health consultation
  • Nutritional counseling
  • Exercise counseling
  • Support programs

Referrals & Authorizations

While Western Health Advantage is your health plan and we review prior authorization (pre-approval) for some services, certain covered services require prior authorization directly from your affiliated (assigned) medical group. This is required to make sure services are covered and paid for under your health plan benefits. 

Your Primary Care Physician should know when pre-approval is needed. PCP staff will notify your medical group or WHA when you need to see a specialist or get another service that requires pre-approval. Decisions are made by qualified medical professionals (doctors, pharmacists and nurses), but only experienced physicians and pharmacists can deny or modify a requested service.