Medical Exception Process

• During Q1 and Q2, reports will be run to identify any impacted claims (based on gender dysphoria codes) for dates of service prior to 1/1/2026. These claims will be used to identify member impact and document within our system the members who are requesting the continuation of procedures that were initiated with SAMBA during Plan Year 2025 or a carrier that has terminated from the FEHB program.

• Verification that the patient is 19 years of age or older will take place.

• Denial and approval communications are sent to both the provider and the patient. Coverage denial communications will include the right to appeal and inform the patient of the Disputed Claims Process as outlined in Section 8 of the SAMBA Health Benefit Plan brochure.

• The same exceptions process will be utilized to determine authorization of sex trait modification procedures for members who elect to use out-of-network providers.