Earlier this month, UnitedHealthcare (UHC) announced an updated policy on pharmacogenetic (PGx) testing. Starting in October, though timing may vary by region, the official policy will cover PGx testing for patients with major depressive disorder and/or anxiety who have experienced treatment failure at least once. UHC considers PGx testing for these patients both proven and medically necessary.

This is great news for the industry, as this policy demonstrates that the country’s largest insurer recognizes PGx testing as a potentially valuable asset in patient care. But what does this decision really mean for providers?

1. Improved patient access to valuable medical services

Patient access is a key element of the quadruple aim for healthcare, but when we think about access, it’s easy to get caught in the mindset of doctor’s appointments. Access to care is more than just being able to physically get to a doctor, it encompasses things like coverage and cost for medical services. And newer services like PGx testing are less likely to be covered by medical insurance.

While costs for genetic testing have been steadily decreasing, genetic tests not covered by insurance can still present a cost obstacle for some patients. By covering PGx testing - even for a limited population - UHG is expanding access to valuable information that providers can use to help their patients.

2. Information that can be used for prescribing beyond depression and anxiety

UHC’s policy is focused on a very specific population and condition set. Depression, in particular, is a strong use case for PGx testing. According to the Anxiety and Depression Association of America, nearly 7% of U.S. adults have major depressive disorder. With a variety of antidepressants on the market, providers have options for treatment, but approximately half of people don’t see the desired effect from their first antidepressant, according to a study published in the American Journal of Psychiatry. PGx information can help providers identify the option(s) that are most likely to provide relief for individual patients.

Even when PGx is only covered for specific conditions and circumstances, the information can be used across specialties and for years to come. PGx testing provides information on specific genes and genetic variants, which don’t change over time. Providers can use the genotype and phenotype information from PGx tests in prescribing decisions beyond choosing an antidepressant or anxiety medication. The FDA has pharmacogenomic biomarker labeling on more than 200 drugs that span numerous specialties and conditions.

Providers who order the RightMed test can consult with our expert pharmacists for help interpreting the genotype and phenotype information for individual patients.

3. One big step forward

Generally, major shifts in how insurance covers medical services come from decisions by the Centers for Medicare and Medicaid (CMS). In this instance, a commercial insurer is leading the charge. This tells me that insurers are seeing the value that PGx can bring - to both patients and their businesses in the form of cost savings. A recent study found that PGx testing can reduce unnecessary healthcare utilization. Patients with PGx results had 40% fewer emergency department visits and 58% fewer hospitalizations than those who hadn’t received PGx testing.1

UHC’s PGx policy is a big step forward for PGx and a wonderful move for the many patients who will be covered. I anticipate that this is the beginning of a larger trend toward insurance coverage for PGx. Other insurers are likely to adjust—or at least review— their policies on PGx testing in the wake of UHC’s announcement. And once insurers see the value PGx brings, both in outcomes and in cost savings, we’ll begin seeing coverage expand to other patients and use cases.

References

1 Perlis et al., 2017; Depression and Anxiety, 35(10), 946–952.
Julie England
About julie