Insurance Companies Wrestle With Coverage for Pharmacogenomic Tests

As the age of individualized medicine dawns, major health insurance companies are wrestling with the question of whether or not to pay for FDA approved Pharmacogenomic tests. Pharmacogenomic testing is designed to test a persons genetic make-up to determine the effectiveness of a given treatment, specifically how they will react to certain drugs. The tests are at the cornerstone of a dynamic shift in medicine to "individualized medicine” based on a persons DNA. Pharmacogenomic tests are expensive, so insurance companies are not anxious to pay for them; however advocates say that they will save insurance companies money in the long run, by determining the most effective treatments for a given patient. This way the health insurance will not be paying out for treatments that will not work, only to then pay again as doctors search for a more effective treatment.

According to the insurance industry there has been a 20% increase in request for payments for genetic diagnostic tests this year. One well-known insurer, Aetna has stated that they will be using the same criteria to determine if they will pay for genetic diagnostic and Pharmacogenomic tests as they do for other types of tests. IE:

• Are the tests FDA Approved?
• What is the purpose of the Testing?
• Have the tests been peer reviewed for efficacy?
• Is the testing under a health benefit or a disability benefit? Will paying for the Test help financial decision making in the future?

Aetna also says it looks at the clinical utility of a test before making a determination of payment eligibility for those holding an Aetna health insurance policy. "We look to see if a given test improves net health outcomes, or are more beneficial then traditional or alternative treatments”, said a spokesperson for the company. They went on to say that the company uses the same basic principals of coverage to form policy on payment for genetic tests as they do for non-genetic tests, which include but are not limited to:

• Is the service related to the prevention diagnosis or treatment of a disease or illness?
• Will the resultant information from the test affect the course of treatment of the insured?
• Is the test likely to result in an improved outcome for the insured?

Joanne Armstrong Senior Medical Director at Aetna pointed out the effectiveness of this policy in the past. She said the company saved millions by approving genetic testing that determines through genotype the effectiveness if Interferon treatment for those suffering from Hepatitis C.