Insurance Coverage Policies for Pharmacogenomic and Multi-Gene Testing for Cancer

Journal of Personalized Medicine
Christine Y LuAnn Chen Wu

Abstract

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-recomme...Continue Reading

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Citations

May 21, 2020·Journal of Genetic Counseling·Emily ThoresonChelsea Wagner
Sep 6, 2019·JCO Clinical Cancer Informatics·Andrea N Burnett-HartmanChristine Y Lu
Feb 6, 2019·Journal of Personalized Medicine·Rachele M Hendricks-Sturrup, Christine Y Lu
Jul 4, 2019·Journal of Personalized Medicine·Rachele M Hendricks-SturrupChristine Y Lu
Apr 1, 2020·Journal of Managed Care & Specialty Pharmacy·Devender S DhandaJosh J Carlson
Apr 16, 2020·Genetics in Medicine : Official Journal of the American College of Medical Genetics·Heather D AndersonChristina L Aquilante
Apr 3, 2021·Therapeutic Advances in Drug Safety·Aisling R Caffrey, Eric P Borrelli
Jan 28, 2021·Genetics in Medicine : Official Journal of the American College of Medical Genetics·Anthony Scott, Donna M Martin

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