Reimbursement of pharmacogenetic tests at a tertiary academic medical center in the United States

Lauren K Lemke; Benish Alam; Roy Williams; Petr Starostik; Larisa H Cavallari; Emily J Cicali; Kristin Wiisanen

doi:10.3389/fphar.2023.1179364

Reimbursement of pharmacogenetic tests at a tertiary academic medical center in the United States

Front Pharmacol. 2023 Aug 14:14:1179364. doi: 10.3389/fphar.2023.1179364. eCollection 2023.

Authors

Lauren K Lemke^{1

2}, Benish Alam^{1

2}, Roy Williams¹, Petr Starostik^{3

4}, Larisa H Cavallari^{1

2}, Emily J Cicali^{1

2}, Kristin Wiisanen^{1

2}

Affiliations

¹ Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL, United States.
² Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, United States.
³ Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States.
⁴ UF Health Pathology Laboratories, UF Health, Gainesville, FL, United States.

Abstract

Introduction: Pharmacogenetics (PGx) has the potential to improve health outcomes but cost of testing is a barrier for equitable access. Reimbursement by insurance providers may lessen the financial burden for patients, but the extent to which PGx claims are covered in clinical practice has not been well-characterized in the literature. Methods: A retrospective analysis of outpatient claims submitted to payers for PGx tests from 1/1/2019 through 12/31/2021 was performed. A reimbursement rate was calculated and compared across specific test types (e.g., single genes, panel), payers, indication, and the year the claim was submitted. Results: A total of 1,039 outpatient claims for PGx testing were analyzed. The overall reimbursement rate was 46% and ranged from 36%-48% across payers. PGx panels were reimbursed at a significantly higher rate than single gene tests (74% vs. 43%, p < 0.001). Discussion: Reimbursement of claims for PGx testing is variable based on the test type, indication, year the claim was submitted, number of diagnosis codes submitted, and number of unique diagnosis codes submitted. Due to the highly variable nature of reimbursement, cost and affordability should be discussed with each patient.

Keywords: insurance coverage; payer; pharmacogenetics; pharmacogenomics; reimbursement.

Grants and funding

Research reported in this publication was supported by the University of Florida Clinical and Translational Science Institute, which is supported in part by the NIH National Center for Advancing Translational Sciences under award number UL1TR001427. In addition, research reported in this publication was supported by NIH National Human Genome Research Institute under award number U01HG007269. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.