Does blue cross blue shield of illinois cover testosterone treatment

Blue Cross Blue Shield of Illinois was sued in federal court on Monday by the parents of a 15-year-old who allege the insurer’s policies deny transgender individuals of “coverage for medically-necessary treatment of gender dysphoria.”

The plaintiff, Patricia Pritchard, receives health coverage through the Catholic Health Initiatives Medical Plan, administered by BCBSIL, with her son, “C.P.,” a dependent. The suit, brought on behalf of the parents by civil rights group Lambda Legal, was filed in the U.S. District Court for the Western District of Washington, and alleges BCBSIL denied coverage for C.P.’s gender dysphoria.

BCBSIL covered some of C.P.’s treatments, including testosterone injections and mental health counseling, but later denied coverage, according to the suit. In Oct. 2016, BCBSIL initially approved C.P.’s request for preauthorization for a Vantas implant to delay the onset of female puberty. C.P. received the implant in Nov. 2016 and BCBSIL made payment for the treatment, the complaint says.

In April 2017, C.P.’s mother received a letter from the insurer claiming coverage would be denied because “treatment for transgender services were allowed incorrectly under the medical plan.”

The plan didn’t specifically exclude coverage for gender-reassignment or gender dysphoria treatments in 2017, the suit alleges, with BCBSIL only adding an exclusion starting on Jan. 1, 2018.

“Benefits shall not be provided for treatment, drugs, medicines, therapy, counseling services and supplies for, or leading to, gender reassignment surgery,” the policy states, according to the complaint.

“Other Plan enrollees who are not transgender do not face a categorical exclusion barring coverage for health care that is medically necessary for them based on their sex and receive coverage for the same care that is denied to transgender enrollees,” the complaint adds.

The lawsuit alleges the “sweeping exclusion” violates the nondiscrimination provisions under Section 1557 of the Affordable Care Act.

“Section 1557 of the ACA expressly prohibits categorical bans on gender-affirming care because it is discrimination on the basis of sex, plain and simple,” Omar Gonzalez-Pagan, senior attorney and health care strategist for Lambda Legal, said in a statement Monday.

The suit seeks damages and an order enjoining BCBSIL from excluding coverage for gender dysphoria treatments.

Cause of Action: Section 1557 of the Affordable Care Act.

Relief: Order enjoining BCBSIL from “administering or enforcing health plans that exclude coverage for gender-affirming health care,” damages, attorney fees and costs.

Response: Blue Cross Blue Shield of Illinois did not immediately respond to a request for comment.

Attorneys: Lambda Legal and Sirianni Youtz Spoonemore Hamburger PLLC are representing the plantiffs.

The case is P. et al v. Blue Cross Blue Shield of Ill., W.D. Wash., No. 3:20-cv-06145, Complaint filed 11/23/20.

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Blue Cross and Blue Shield of Illinois' (BCBSIL) prior authorization/step therapy program is designed to encourage safe, cost-effective medication use. Most HMO groups and standard products plans include this program. Self-insured and custom fully insured groups offer a variety of these programs to help effectively manage their prescription drug benefit.

Prior Authorization

Under this program, the member's physician will be required to obtain authorization from BCBSIL in order for the member to receive benefits for certain medications and drug categories.

Below are drug categories and specific medications* for a prior authorization program included in the standard utilization management package, which applies for most standard pharmacy benefit plans. Please note that not all drug categories are included in all plans, and medications may change from time-to-time. For the most up-to-date list, members should call the Pharmacy Program number on the back of their BCBSIL ID card.

As always, cost is only one factor in choosing medication, and treatment decisions are between the member and physician.

Addyi

• Addyi

Afrezza

• Afrezza

Androgens/Anabolic Steroids

Antifungal Agents

Circadian Rhythm Disorders (formerly Hetlioz)

• Hetlioz

Doxycycline/Minocycline

Erectile Dysfunction (ED)

Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker

Insulin Agents

Narcolepsy

• Nuvigil
• Provigil
• Xyrem is also included in this program. See separate entry in Specialty Prior Authorization section.

Neprilysin Inhibitor

• Entresto

Ophthalmic Immunomodulators

• Restasis
• Xiidra

Opioid Dependence

• Bunavail
• Suboxone
• Subutex
• Zubsolv

Opioid Induced Constipation

• Movantik
• Relistor

Oral Immunotherapy

• Grastek
• Oralair
• Ragwitek

Therapeutic Alternatives

Topical Antifungal Agents

Transmucosal Immediate Release Fentanyl

Specialty Prior Authorization

Cerdelga

• Cerdelga

Cystic Fibrosis

• Kalydeco
• Orkambi

Enzyme Deficiency

• Kuvan

Erythropoiesis Stimulating Agents (ESAs)

• Aranesp
• Epogen
• Mircera
• Procrit

Growth Hormone/Egrifta

H.P. Acthar (Pituitary Hormone)

• H.P. Acthar Gel

Hepatitis B & C

Huntington's Chorea

• Xenazine

Hypercholesterolemia

• Juxtapid
• Kynamro
• Praluent
• Repatha

Idiopathic Pulmonary Fibrosis (IPF)

• Esbriet
• Ofev

Inherited Autoinflammatory Disorders

• Arcalyst

Korlym

• Korlym

Multiple Sclerosis

• Ampyra

Myalept

• Myalept

Natpara

• Natpara

Ocaliva

• Ocaliva

Osteoporosis

• Forteo

Pulmonary Arterial Hypertension (PAH)

Self-Administered Oncology

Short Bowel Syndrome

• Gattex

Thrombopoietin Receptor Agonists

• Promacta

Urea Cycle Disorders

• Buphenyl
• Ravicti

Xyrem

• Xyrem

Step Therapy

Step therapy is a type of prior authorization. In order for a member to receive coverage for drugs included in this program, the physician will be required to obtain authorization from BCBSIL.

As an alternative to asking their doctor to receive prior authorization, or paying the entire cost of the medication out-of-pocket, members, along with their physician, may decide that a lower-cost generic or brand alternative medication that is not part of the program is an appropriate option. The plan will provide benefits for medications included in the program when the member first tries a lower-cost medication or the doctor obtains prior authorization of coverage through BCBSIL.

Below are drug categories and specific medications* for a step therapy program included in the standard utilization management package, which applies for most standard benefit plans. Step therapy does not apply to the generic equivalents for these medications (if available). If the member and physician decide the generic equivalent is an appropriate option, the member will not need to go through the prior authorization process.

Please note that not all drug categories are included in all plans, and medications may change from time-to-time. For the most up-to-date list, members should call the Pharmacy Program number on the back of their BCBSIL ID card.

Please note: These medications are listed along with the first use approved by the U.S. Food and Drug Administration, but may be prescribed for conditions other than those noted and would still be part of the step therapy program.

As always, cost is only one factor in choosing medication, and treatment decisions are between the member and doctor.

Atopic Dermatitis

• Elidel
• Protopic/tacrolimus

Atypical Antipsychotics

Cox-2/NSAID GI Protectant (Pain Management)

• Celebrex
• Duexis
• Vimovo

Depression

Diabetes (GLP-1 Receptor Agonists)

• Bydureon
• Byetta
• Tanzeum
• Trulicity
• Victoza

Fibrates

Glucose Test Strips

• All non-preferred brand test strips and disks

Lipid Management (Cholesterol)

Ophthalmic Prostaglandins

Topical Non-Steroidal Anti-Inflammatory Drug

• Flector
• Pennsaid
• Voltaren

Specialty Step Therapy

Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis)

Infertility**

• Bravelle
• Gonal
• Gonal F RFF

Iron Chelator

• Ferriprox

Multiple Sclerosis

• Aubagio
• Avonex
• Extavia
• Gilenya
• Zinbryta

Members should call the Pharmacy Program number on the back of their BCBSIL ID card with questions about the prior authorization/step therapy program.

* Third-party brand names are the property of their respective owners.

** The infertility step therapy program does not apply for standard HMO plans.

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