Gender-Affirming Care Coverage Guide

In 2023, Colorado became the first state in the country to explicitly include gender-affirming care services in its benchmark health insurance plan for essential health benefits (EHBs). The benchmark plan that became effective January 1, 2023, lays out these  services that insurance companies must cover for individual plans (meaning not from an employer) and small group plans (for small employers with 2 - 100 employees). 

Each person’s gender-affirming care plan varies, and could include a combination of mental and behavioral health care, hormone therapy, and/or different surgical procedures, depending on the source of their gender dysphoria. It can be challenging to pick the right health insurance that meets your needs. The Division of Insurance offers this review of the individual plans for purchase on Connect for Health Colorado, the state’s marketplace exchange, as well as off of the exchange. 

Please note that the information below is not an exhaustive list of all gender-affirming care procedures, but rather a  list of many common services to treat gender dysphoria. It also does not include the different processes, like prior authorization or letters from a provider, that may be required by an insurance company in order to show that it is medically necessary to receive a service or medication. When pursuing a gender-affirming care treatment plan, it is important to inquire with the insurance company in writing to understand the scope and specificity of procedures, medications, and other resources that may be covered or offered. 

The information below displays a list of gender-affirming services and how they are covered by each insurance company offering individual and small group plans for 2024. If you are looking for information for 2023, please contact Cyndi Eddington at cyndi.eddington@state.co.us. 

If you have any questions, please contact the Consumer Services Team for assistance: 303-894-7490 / DORA_Insurance@state.co.us / File a Complaint.

The table below can be used to review the coverage and forms of hormone therapy by each insurance company. Not all health plans cover all drugs or put them on the same tiers. Each insurance company has a list of prescriptions they cover, called a formulary or drug list, on their website.  These lists often split drugs into ‘tiers’ or categories, which determine your share of the costs. 

While some plans have a copay for prescriptions—a fixed amount that starts right away—other plans require you to pay the full cost until you hit a prescription deductible (if there is one) or your overall plan deductible, which is more common. This table does not review each plan offered through each carrier. 

Lower tiers generally mean generic and lower-cost drugs. Middle tiers often include brand name drugs. Higher tiers generally include specialty drugs or drugs administered in a medical facility. Each company tiers drugs differently, so it is important that you look at each plan specifically to see what medications may cost you. This is a summary of hormone therapy drugs available, but may not be an exhaustive list. 

Want to know if your prescription medication is covered? You can use the Quick Cost and Plan Finder tool offered by Connect for Health Colorado. 

If you have any questions please contact the Division of Insurance Consumer Services Team at 303-894-7490 / DORA_Insurance@state.co.us. You can also file a complaint online on the "File a Complaint" page of our website.

In the table below for Hormone Therapies: 

• NC = Not Covered; MD = Medication Covered under Medical Benefit
• The numbers listed are equal to the tier for specific medication as assigned by carrier. This often informs member cost share, with higher tiers typically associated with higher cost-share.

Mental and behavioral health is just as important as one’s physical health, and may be an integral component on someone’s gender-affirming treatment plan. In Colorado, consumers have a number of protections related to affordability, access, and network adequacy – the ability to find a provider that can serve your whole identity. More information about those services, rights, and protections can be found on the Division’s Mental / Behavioral Health and Insurance website. 

Appeals if Your Request is Denied

If you do receive a prior authorization denial or a post-service from your insurance company for your care you do have appeal rights. Individual plans, such as those you purchase yourself and that you don’t get through your employer, have a first level appeal process where they will re-review their denial if you or your care team file an appeal request within 180 days of the denial. Even if the denial is upheld after appeal, if it was denied as not being medically necessary, you may be able to request an independent external review by an independent third-party assigned by the Division. The results of an independent external review are binding on both the insurance company and the individual.

If you have any questions about prior authorization requests, appeals, denials, or a request for external review, please contact the Division of Insurance Consumer Services Team at 303-894-7490 / DORA_Insurance@state.co.us. You can also file a complaint online on the "File a Complaint" page of our website.