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

dc.contributor.authorClayton, Ellen Wright
dc.contributor.authorLoomer, Stephanie
dc.contributor.authorLu, Christine Y.
dc.contributor.authorCeccarelli, Rachel
dc.contributor.authorMazor, Kathleen M.
dc.contributor.authorSabin, James
dc.contributor.authorGinsburg, Geoffrey S.
dc.contributor.authorWu, Ann Chen
dc.date.accessioned2018-11-05T22:17:55Z
dc.date.available2018-11-05T22:17:55Z
dc.date.issued2018
dc.identifier.citation8 (2) Journal of Personalized Medicine 19 (2018)en_US
dc.identifier.urihttp://hdl.handle.net/1803/9316
dc.descriptionarticle published in a medical journalen_US
dc.description.abstractAbstract: 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.en_US
dc.format.extent1 PDF (15 pages)en_US
dc.format.mimetypeapplication/pdf
dc.language.isoen_USen_US
dc.publisherJournal of Personalized Medicineen_US
dc.subjectpharmacogenomics; multi-gene testing; cancer; insurance coverage; tumor markersen_US
dc.subject.lcshlawen_US
dc.subject.lcshinsurance lawen_US
dc.titleInsurance Coverage Policies for Pharmacogenomic and Multi-Gene Testing for Canceren_US
dc.typeArticleen_US


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