Meyers Primary Care Institute
Analytical, Diagnostic and Therapeutic Techniques and Equipment | Health Economics | Health Policy | Health Services Administration | Health Services Research | Insurance | Medical Genetics | Neoplasms
Insurance coverage policies are a major determinant of patient access to genomic tests. The objective of this study was to examine differences in coverage policies for guideline-recommended pharmacogenomic tests that inform cancer treatment. We analyzed coverage policies from eight Medicare contractors and 10 private payers for 23 biomarkers (e.g., HER2 and EGFR) and multi-gene tests. We extracted policy coverage and criteria, prior authorization requirements, and an evidence basis for coverage. We reviewed professional society guidelines and their recommendations for use of pharmacogenomic tests. Coverage for KRAS, EGFR, and BRAF tests were common across Medicare contractors and private payers, but few policies covered PML/RARA, CD25, or G6PD. Thirteen payers cover multi-gene tests for nonsmall lung cancer, citing emerging clinical recommendations. Coverage policies for single and multi-gene tests for cancer treatments are consistent among Medicare contractors despite the lack of national coverage determinations. In contrast, coverage for these tests varied across private payers. Patient access to tests is governed by prior authorization among eight private payers. Substantial variations in how payers address guideline-recommended pharmacogenomic tests and the common use of prior authorization underscore the need for additional studies of the effects of coverage variation on cancer care and patient outcomes.
cancer, insurance coverage, multi-gene testing, pharmacogenomics, tumor markers
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© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. (CC BY 4.0).
DOI of Published Version
J Pers Med. 2018 May 16;8(2). pii: jpm8020019. doi: 10.3390/jpm8020019. Link to article on publisher's site
Journal of personalized medicine
Lu, Christine Y.; Loomer, Stephanie; Ceccarelli, Rachel; Mazor, Kathleen M.; Sabin, James; Clayton, Ellen Wright; Ginsburg, Geoffrey S.; and Wu, Ann Chen, "Insurance Coverage Policies for Pharmacogenomic and Multi-Gene Testing for Cancer" (2018). Open Access Articles. 3466.
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.
Analytical, Diagnostic and Therapeutic Techniques and Equipment Commons, Health Economics Commons, Health Policy Commons, Health Services Administration Commons, Health Services Research Commons, Insurance Commons, Medical Genetics Commons, Neoplasms Commons