Study Data from Atrium Health Update Knowledge of Life Science (Medical Policy Determinations for Pharmacogenetic Tests Among Us Health Plans): Life Science

2025 MAR 26 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- Researchers detail new data in Life Science. According to news reporting originating from Charlotte, North Carolina, by NewsRx correspondents, research stated, “To evaluate medical policy determinations for pharmacogenetic (PGx) testing for 65 clinically relevant drug-gene pairs and evidence cited to support determinations across major US health plans and laboratory benefit managers (LBMs). Landscape analysis of available PGx medical policies to determine coverage status of certain drug-gene pairs.”

Our news editors obtained a quote from the research from Atrium Health, “PGx medical policies as of February 1, 2024, were ascertained through Policy Reporter for top national insurers, LBMs, and the Palmetto GBA Molecular Diagnostic Services (MolDX) Program, which determines whether a molecular diagnostic test is covered by Medicare. Data elements included date of last policy update, coverage status for each drug-gene pair, and evidence cited for or against coverage. A drug-gene pair was considered covered if the policy indicated that a PGx test was deemed medically necessary and/or meets coverage criteria. Policies from 8 insurers, 3 LBMs, and MolDX were available and reviewed. MolDX covered all 65 individual drug-gene pairs, followed by Avalon Healthcare Solutions (n = 50) and UnitedHealthcare (n = 45); these 3 also covered multigene panels. Eight policies covered 10 or fewer drug-gene pairs. HLA-8*57:01 testing prior to abacavir initiation and HLA-8*15:02 testing priorto carbamazepine initiation were covered across all policies. Drug-gene pairs with Clinical Pharmacogenetics Implementation Consortium guidelines and/or included in the FDA’s Table of Pharmacogenetic Associations Section 1 were more commonly covered. Society guidelines were the most frequently cited evidence (413 times), and cost-effectiveness studies were infrequently cited (43 times). We found significant variability in medical policy determinations and evidence cited for clinically relevant PGx tests among major US health insurers and LBMs.”

According to the news editors, the research concluded: “A collaborative effort between payers and the PGx community to standardize evidence evaluation may lead to more consistent coverage and improve patient access to PGx tests meeting evidence requirements.”

This research has been peer-reviewed.

For more information on this research see: Medical Policy Determinations for Pharmacogenetic Tests Among Us Health Plans. American Journal of Managed Care, 2025;31(2). American Journal of Managed Care can be contacted at: Managed Care & Healthcare Communications Llc, 666 Plainsboro Rd, Ste 300, Plainsboro, NJ 08536, USA.

The news editors report that additional information may be obtained by contacting Jai N. Patel, Atrium Health, Levine Cancer Institute, Div Canc Pharmacol & Pharmacogen, 1021 Morehead Med Dr, Charlotte, NC 28204, United States. Additional authors for this research include Lena Chaihorsky, Olivia M. Dong, Christine Y. Lu, Chad Moretz, Emily Reese, Wrenda Teeple, Benjamin Brown and Sara Rogers.

The direct object identifier (DOI) for that additional information is: https://doi.org/10.37765/ajmc.2025.89683. This DOI is a link to an online electronic document that is either free or for purchase, and can be your direct source for a journal article and its citation.

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