For employees on a UM health plan (such as GradCare), cross-sex Hormone Replacement Therapy (HRT) can now be initiated on the basis of informed consent. This means that employees do not need to submit a psychological letter of support to be eligible for an HRT prescription.

In theory, letters of support function strictly to establish medical necessity. In practice, they are widely perceived as a gauntlet to determine who is “trans enough” for hormones, and have been notorious in how they can function as barriers to accessing care. Originating in what were known as the Harry Benjamin Standards of Care (now called WPATH) back in 1979, they were historically designed with the intent of enforcing a false and deeply sexist stereotype of what it means to “really be” trans.

On a basic level, this system is wrong. It’s your body, and transition should fundamentally be your choice. We are therefore very excited to hear that U of M will affirm your right to make an informed choice, in consultation with relevant medical professionals. Under an informed consent model, physicians are empowered to make decisions about medical necessity without the historical, logistical, and emotional baggage placed on patients by letters of support. Informed consent is an important trans rights issue, and U of M is taking an important step forward by enabling patients to access covered HRT without requiring these letters.

How does starting hormones on informed consent work?

Requests to initiate HRT can be made by scheduling an appointment with one of the Michigan Medicine providers listed on the following webpage:

https://www.uofmhealth.org/conditions-treatments/transgender-services/hormone-therapy

Providers within the OB-GYN department at Michigan Medicine listed on the above page will see patients without requiring letters. All providers reserve the right within their practice to decide, on a case-by-case basis, whether to recommend working with a mental health clinician, though a letter will not be required to meet with the prescriber/physician who prescribes hormones. So long as the provider is confident with giving the go-ahead, they are fully empowered to write a hormone prescription for the patient without a letter. The patient may then proceed to get their HRT prescription filled as they would with any other prescription.

What about insurance coverage?

Visits with the prescriber/physician to discuss hormones are covered (though there may be applicable copays), and importantly, the UM prescription drug plan does not require a letter as part of the prior authorization process for hormone therapy. In fact, for estrogen therapy, no prior authorization is required at all. For testosterone therapy, BCN says that the prescriber/physician needs to attest that the prescription is for gender dysphoria (and during renewal, that levels are within the normal range) due to the potential for off-label substance abuse.

Does this apply to surgical procedures?

No. At this time, either one or two (depending on the procedure) letters of support are required to obtain transition-related surgery, as specified in Revision 7 of the WPATH Standards of Care (2011). GEO maintains the position that this requirement can create unreasonable barriers to accessing medically necessary healthcare benefits. To the best of our knowledge, there has never been a controlled study that compares the requirement of two letters to the requirement of only one — that is, we believe that the requirement of a second letter has no grounding in scientific evidence. Moreover, we believe that the barriers arising from this requirement are incompatible with the goals outlined in the University’s Diversity, Equity, & Inclusion plan. We are therefore actively investigating whether there are any avenues through which we can help facilitate improved, equitable access to appropriate surgical care for our members, but at present, we do not have any updates to report.