Format

Send to

Choose Destination
J Pers Med. 2018 May 16;8(2). pii: E19. doi: 10.3390/jpm8020019.

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

Author information

1
Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA. christine_lu@harvardpilgrim.org.
2
Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA. stephanie_loomer@harvardpilgrim.org.
3
Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA. ceccare1@msu.edu.
4
Meyers Primary Care Institute, A Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group and Fallon Health; 630 Plantation Street, Worcester, MA 01605, USA. Kathy.Mazor@meyersprimary.org.
5
Departments of Population Medicine and Psychiatry, Harvard Medical School, Boston, MA 02115, USA. jim_sabin@harvardpilgrim.org.
6
Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN 37232, USA. ellen.clayton@vanderbilt.edu.
7
Duke Center for Applied Genomics and Precision Medicine, Duke University Medical Center, Durham, NC 27710, USA. geoffrey.ginsburg@duke.edu.
8
Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA. ann.wu@childrens.harvard.edu.

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-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.

KEYWORDS:

cancer; insurance coverage; multi-gene testing; pharmacogenomics; tumor markers

Supplemental Content

Full text links

Icon for Multidisciplinary Digital Publishing Institute (MDPI) Icon for PubMed Central
Loading ...
Support Center