Insurance Coverage for Genetic Testing and Personalized Medicine: Which Way Is the Wind Blowing?

Alice Goodman

June 2014, Vol 5, No 5 - Economics of Cancer Care


Tampa, FL—Genetic testing and targeted medicines, the key players in personalized medicine, are seen as the waves of the future for managing patients with cancer, but getting there remains a challenge when it comes to insurance coverage for these expensive tests and therapies. Little is known about the current coverage, payers’ attitudes about future expansion of coverage, and the determinants of that coverage.

A recent survey presented at the 2014 Academy of Managed Care Pharmacy meeting elicited some answers to these questions. The majority of payers currently cover at least some genetic testing and targeted therapies, and plan to evaluate the need for expanded coverage of these services, according to the survey results.

One of the most important findings from this study is that payers need more pharmacoeconomic data showing the value of genetic testing as it relates to the selection of therapy and patient outcomes to make coverage decisions.

“Many of the new medications are specialty pharmaceuticals, and many have genetic tests to go along with them. We wanted to see if payers are onboard with advances in pharmacogenomics. The majority of payers are interested in expanding coverage for these services, but need more pharmacoeconomic data to demonstrate cost-effectiveness,” lead investigator Nisreen Shamseddine, MS, of Xcenda, Palm Harbor, FL, told Value-Based Cancer Care.

“Of the 100s of genetic tests listed in the National Comprehensive Cancer Network Biomarker Compendium, decision makers do not know which ones have value. The take-home message of our study is that, overall, genetic testing is important to decision makers, but they are currently operating without full information. They need more information, with pharmacoeconomic data being one of those missing pieces,” noted coinvestigator Melissa S. Denno, PharmD, MS, Manager, Global Health Economics and Outcomes Research, Xcenda.

The study was based on a double-blind online survey conducted between July 18 and August 4, 2013. The survey consisted of 28 questions about current and future coverage decisions regarding genetic testing and personalized medicine, including health economic questions.

The 60 respondents included pharmacy and medical directors representing coverage of 107 million lives. Regional plans (60%) and national plans (38%; 2% unspecified) representing commercial, Medicare, and/or Medicaid plans were included. The types of plans included managed care organizations, integrated health delivery systems, preferred provider organizations, and pharmacy benefit managers.

Coverage Trends in Oncology
Overall, 90% of respondents said they currently covered some form of genetic testing, with approximately 40% of plans covering between 76% and 100% of the cost. Slightly more than 83% of the respondents noted that requests for genetic testing from physicians and patients have increased over the past 5 years.

In all, 68% of respondents plan to increase coverage for genetic testing over the next 5 years compared with 5% who want to decrease coverage, approximately 17% who want to maintain the same coverage, and 10% who are unsure.

The majority (98.3%) of respondents identified cancer as the disease state in which genetic testing was likely to have the most significant impact on patient outcomes.

When asked which available biomarkers were currently covered by plans, the 2 most frequently covered were HER2 for breast cancer (95% of plans) and KRAS mutation testing for metastatic colorectal cancer (91.7%).

Respondents said that literature was scarce about the cost-effectiveness of genetic testing and personalized medicine; 45.7% of respondents believed that personalized medicine would increase the cost of care for their plans.

A large majority (83.4%) of plans believed that genetic testing would dictate decisions about treatment selection. When asked what factors were clinically important for personalized medicine, the 3 most frequently named factors were:

  • Predicting response to an agent
  • Getting the most effective therapy the first time
  • More efficient management of cost.