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13
Feb 2019

Q. Will my insurance cover the costs for this?

By boadmin11

Most diagnostic test companies will accepts all insurance plans. However, that doesn’t mean your insurance company will agree to cover the costs. It is very possible that the test provider will not be in-network with the providers in your insurance plans. If you are uninsured, or if you have insurance and cannot afford the applicable out-of-pocket cost, you also have options. You can fill out a financial assistance application from the diagnostic test companies

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to determine upfront what your maximum out-of-pocket expense might be. Payment plans may also be available.

Regarding coverage, fortunately, the Centers for Medicare & Medicaid Services (CMS) issued a final National Coverage Determination (NCD) for patients who receive next generation sequencing (NGS) testing with an assay that meets the coverage criteria. Medicare and Medicare Advantage patients who receive testing with FoundationOne CDx™ (from Foundation Medicine) the first FDA-approved comprehensive genomic profiling (CGP) assay for all solid tumors incorporating a broad set of companion diagnostics, will be eligible for coverage.

For those who have private health insurance coverage through employers, or direct purchase coverage, here is some strategic guidance to get those tests covered by insurance. First, push your physician to order the test and ask them to communicate to your insurance company that you have recurrent, relapsed, refractory, metastatic, or advanced (stage III or IV) cancer (assuming this is the case for your condition). Include the fact that you’ve decided to seek further cancer treatment, and that you haven’t previously been tested using the same next generation sequencing (NGS) test that your doctor is ordering for you. If you are denied / rejected by insurance than try and seek financial assistance from the diagnostic testing company or hospital / cancer center that is offering the service. If this still fails to address the payment issue, we’d like to hear from you. Sequenceme.org isn’t set up to provide financial assistance for these tests, but we’re more than happy to use social media to shine a light on organizations that are pushing back on enabling you to get these tests approved and covered.

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