"Although it is not possible to list every situation or procedure that is noncovered through the Physician Program, the following list has been compiled: ...

Surgical procedures for gender change such as:

• Hysterectomy
• Mammoplasty
• Mastectomy
• Orchiectomy
• Penectomy
• Penile construction
• Release of vaginal adhesions
• Revision of labia
• Vaginal dilation
• Vaginal reconstruction
• Vaginoplasty;"

State of Missouri Physician Manual (2019), p. 226-227.