Better Coverage Needed for Increasing Trend of Genetic Testing Utilization

An increase in genetic testing expenditures in specialty pharmacy requires improved coverage as utilization and expenditures are expected to grow in the coming years, according to recent research at the 2016 NASP Annual Meeting.

“Specialty pharmacy products treat specific, complex chronic diseases and are costly; require reimbursement and handling assistance or training, have unique and limited distribution processes,” Michael J Sax, Pharm, president of The Pharmacy Group, and wrote in a presentation. “According to IMS Health, specialty medicine spending increased 21.5% in 2015.” 

In order to understand specialty pharmacy health plan management of genetic diagnostic testing products, the researchers surveyed medical and pharmacy directors from public and private plans with multiple member‐types. Survey questions were related to plan information, specialty pharmacies pharmaceuticals, copays, and genetic test coverage restrictions. A total of 212 medical and pharmacy directors were sent the internet-based survey, which had a response rate of 29%.

Survey results showed that 51.7% of coverage plans restricted specialty pharmacy providers from providing genetic testing while 40.3% used their pharmacy benefit managers as their specialty pharmacy. The researchers found that 63.5% of current plans covered all genetic testing, 15.4% did not cover genetic testing, and 21.1% used threshold-based coverage.

The most commonly covered genetic tests were for oncology, with 92.4% and OB/GYN with 66%. 

The researchers also found that disease marker tests for predicting the effectiveness of treatments were fully covered by 79.6% of plans., while 5.6% of plans offered no coverage. 

“Diagnostic and genetic tests identify and predict diseases and treatment response,” Dr Sax and colleagues wrote. “Testing can reduce expenditures by focusing treatments that are effective against disease markers and stopping therapies do not demonstrate a therapeutic response.”  — David Costill