Pharmacogenomics Testing - MEDICAID - OHIO

This policy covers pharmacogenomic testing—laboratory tests that assess how a member’s genetics may affect medication safety and effectiveness—for Ohio Medicaid members for physical and behavioral health indications, including services related to emotional/behavioral dysfunction, developmental disabilities, cognitive impairment, intellectual deficits, and EPSDT-eligible children and adolescents. Coverage requires prior authorization with medical‑necessity documentation and must meet Humana Ohio Medicaid clinical policies, Ohio Administrative Code Chapter 5160, and applicable evidence‑based guidelines (e.g., MCG/ASAM); tests deemed experimental/investigational (e.g., IDgenetix 0411U) are excluded, while emergent services do not require prior authorization.

"In the absence of guidance from Administrative Code, nationally accepted guidelines, or Humana policies, coverage is not automatic; the clinical reviewer will consider other information (see Docume..."