Pharmacogenomic Testing

Medically necessary pharmacogenomic testing is covered when a treating clinician determines a patient needs a medication with known gene-drug interactions and the test results would directly affect drug selection or dosing, provided the test (or actionable components of a panel) meets evidence standards (CPIC level A/B or FDA-listed actionable biomarkers). Coverage is restricted to tests with established analytical/clinical validity and utility, ordered by a qualified treating clinician, and germline testing is limited to one lifetime per beneficiary; duplicate or non-actionable testing is not covered.

"Pharmacogenetic testing is covered when the patient has a condition and clinical evaluation has determined the need for a medication that has known gene-drug interactions and the test results would..."

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