Next Article in Journal
ENABLE 2017, the First EUROPEAN PhD and Post-Doc Symposium. Session 3: In Vitro to In Vivo: Modeling Life in 3D
Previous Article in Journal
Correction: Antoniou, M.; et al. Fixed and Adaptive Parallel Subgroup-Specific Design for Survival Outcomes: Power and Sample Size. J. Pers. Med. 2017, 7, 19
Article Menu
Issue 2 (June) cover image

Export Article

Open AccessArticle
J. Pers. Med. 2018, 8(2), 19; https://doi.org/10.3390/jpm8020019

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

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
2
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
3
Departments of Population Medicine and Psychiatry, Harvard Medical School, Boston, MA 02115, USA
4
Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN 37232, USA
5
Duke Center for Applied Genomics and Precision Medicine, Duke University Medical Center, Durham, NC 27710, USA
*
Author to whom correspondence should be addressed.
Received: 16 April 2018 / Revised: 8 May 2018 / Accepted: 10 May 2018 / Published: 16 May 2018
Full-Text   |   PDF [253 KB, uploaded 21 June 2018]

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. Twelve payers cover at least one multi-gene test for nonsmall cell lung cancer, citing emerging clinical recommendations. Coverage policies for single and multi-gene tests for cancer treatments are relatively 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. View Full-Text
Keywords: pharmacogenomics; multi-gene testing; cancer; insurance coverage; tumor markers pharmacogenomics; multi-gene testing; cancer; insurance coverage; tumor markers
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).
SciFeed

Share & Cite This Article

MDPI and ACS Style

Lu, C.Y.; Loomer, S.; Ceccarelli, R.; Mazor, K.M.; Sabin, J.; Clayton, E.W.; Ginsburg, G.S.; Wu, A.C. Insurance Coverage Policies for Pharmacogenomic and Multi-Gene Testing for Cancer. J. Pers. Med. 2018, 8, 19.

Show more citation formats Show less citations formats

Note that from the first issue of 2016, MDPI journals use article numbers instead of page numbers. See further details here.

Related Articles

Article Metrics

Article Access Statistics

1

Comments

[Return to top]
J. Pers. Med. EISSN 2075-4426 Published by MDPI AG, Basel, Switzerland RSS E-Mail Table of Contents Alert
Back to Top