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PGxHealth Reimbursement Services
Introduction
- The reimbursement environment for the FAMILION tests for inherited cardiac syndromes
has improved significantly during the past three years.
- PGxHealth is devoting increasing resources to assist patients with reimbursement services.
- PGxHealth offers flexible payment plans for patients.
PGxHealth Reimbursement Services
- PGxHealth will assist each patient by working with the insurance provider to pre-authorize
services and determine benefit information upon request.
- PGxHealth will contact the patient with this information prior to the initiation of testing.
- PGxHealth will be quoted an estimate of coverage from the insurance carrier and cannot
guarantee reimbursement.
- Following the completion of testing, PGxHealth will file the insurance claim with the
provider.
FAMILION Patient Assistance Program
Since its inception, PGxHealth has worked to make FAMILION genetic tests as widely available as possible by assisting patients and working with their insurance providers to determine benefits and to gain pre-approval of testing services. Prior to running a test, PGxHealth will always contact the patient with the expected coverage amount and out-of-pocket portion for the test. PGxHealth is an in-network laboratory with many of the nation’s top insurance companies. We are also a Medicare provider and Medicaid provider in 41 States.
The FAMILION Patient Assistance Program can provide resources for patients considering cardiovascular genetic testing by limiting qualified patient out-of-pocket expenses* for FAMILION testing to $500.
For more information about the Patient Assistance Program and to learn more about your eligibility, please contact PGxHealth’s Patient Services Team at 877-2-PGxHealth (877-274-9432) between 9:00 am and 6:30 pm Eastern Time.
* The FAMILION Patient Assistance Program specifically excludes patients with Medicare, Medicaid and all other government run health care programs. Patients covered by in-network insurance contracts and residents of Colorado and Massachusetts are ineligible. Other restrictions may apply.
Select Commercial Payors With Supportive Coverage Policies
- Aetna
- Harvard Pilgrim
- BCBS (AK, AL, AR, HI, ID, IL, MI, MS, NJ, NM, NY, OK, SD, TN, TX, WA)
- Cigna
- Coventry Health Care
- HIP Plan of NY
- Health Net, Inc.
- Humana
- Select Health
- Tufts Health
Select Government Payors With Supportive Coverage Policies
PGxHealth—An Approved Medicaid Provider
- PGxHealth has applied to be an approved Medicaid provider in all 50 states.
- The following states have approved PGxHealth’s application to be a Medicaid provider (as
of January 2010):
- Alabama
- Alaska
- Arizona
- Colorado
- Connecticut
- Florida
- Georgia
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Louisiana
- Maine |
- Maryland
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- Ohio
- Oklahoma
- Oregon
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- Pennsylvania
- South Carolina
- Tennessee
- Texas
- Utah
- Virginia
- Vermont
- Washington
- Washington, DC
- West Virginia
- Wisconsin
- Wyoming
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The FAMILION® Tests—Select Coverage Policies
Aetna
http://www.aetna.com/cpb/medical/data/100_199/0140.html
Blue Cross Blue Shield Technical Evaluation Center (TEC)
http://www.bcbs.com/blueresources/tec/vols/22/22_09.html
Arkansas Blue Cross & Blue Shield (BCBSAR)
http://www.arkansasbluecross.com/members/report.aspx?policyNumber=2006022
Blue Cross & Blue Shield of Tennessee (BCBST)
http://www.bcbst.com/mpmanual/Genetic_Testing_for_Congenital_Cardiac_Channelopathies.htm
Cigna
http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/
mm_0193_coveragepositioncriteria_genetic_testing_for_long_qt_syndrome.pdf
Health Net, Inc.
HIP Plan of New York
https://www.hipusa.com/providers/ny/guidelines/pdf/lab/MG_Long_QT_Testing.pdf
Humana
Humana Medical Policy
Tufts Health Plan
http://www.tuftshealthplan.com/providers/pdf/mng/Genetic_Testing_Long_QT.pdf
Wellmark Blue Cross Blue Shield of Iowa
http://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPolicies/
Policies/Genetic_Molecular_Testing_Misc.aspx
Blue Cross and Blue Shield of Alabama
https://www.bcbsal.org/providers/policies/final/136.pdf
Premera Blue Cross of Alaska
https://www.premera.com/stellent/groups/public/documents/medicalpolicy/cmi_035163.pdf
HMSA Blue Cross and Blue Shield of Hawaii
http://www.hmsa.com/portal/provider/zav_pel.aa.GEN.800.htm
Blue Cross of Idaho
http://www.bcidaho.com/providers/medical_policies/med/mp_20443.asp
Blue Cross and Blue Shield of Illinois
http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=IL1&corpEntCd=IL1&ctype=POLICY
&cat=Medicine&path=/templatedata/medpolicies/POLICY/data/MEDICINE/MED207.110bu_2008-04-15#hlink
Blue Cross and Blue Shield of Mississippi
http://www.bcbsms.com/index.php?q=provider-medical-policy-search.html&action=viewPolicy&path=policy/
emed/Genetic%20Testing%20for%20Congenital%20Long%20QT%20Syndrome.html&keywords=long%20qt%20syndrome
Horizion Blue Cross and Blue Shield of New Jersey
https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf
Blue Cross and Blue Shield of New Mexico
http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=NM1&corpEntCd=IL1&ctype=POLICY&cat=Medicine
&path=/templatedata/medpolicies/POLICY/data/MEDICINE/MED207.110bu_2008-04-15#hlink
Excellus Blue Cross and Blue Shield of New York
https://www.excellusbcbs.com/wps/wcm/connect/787dc7804e8eb7379392bfe420b83c88/
gen_test_long_qt.pdf?MOD=AJPERES
Wellmark Blue Cross and Blue Shield of South Dakota
http://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPolicies/Policies/
Genetic_Molecular_Testing_Misc.aspx
Blue Cross and Blue Shield of Texas
http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=TX1&corpEntCd=IL1&ctype=POLICY&cat=Medicine&path=
/templatedata/medpolicies/POLICY/data/MEDICINE/MED207.110bu_2008-04-15#hlink
Premera Blue Cross of Washington
https://www.premera.com/stellent/groups/public/documents/medicalpolicy/cmi_035163.pdf
ACC/AHA/ESC Guidelines (2006) Recommend
Genetic Testing to Identify ALL Mutation Carriers
in an LQTS Family and in an HCM Family
The ACC/AHA/ESC guidelines for management of patients with ventricular arrhythmias and
prevention of sudden cardiac death recommend genetic testing for numerous congenital cardiac
diseases including those that can identified by the FAMILION tests.
http://circ.ahajournals.org/cgi/reprint/114/10/1088
Long QT Syndrome:
“Genetic analysis is very important for identifying all mutation carriers within an LQTS family:
Once identified, silent carriers of LQTS genetic defects may be treated with beta-blockers for
prophylaxis of life-threatening arrhythmias. Furthermore, silent mutation carriers should receive
genetic counseling to learn about the risk of transmitting LQTS to offspring.”
“In patients affected by LQTS, genetic analysis is useful for
risk stratification and for making therapeutic decisions.
Although genetic analysis is not yet widely available, it is
advisable to try to make it accessible to LQTS patients.”
Catecholaminergic Polymorphic
Ventricular Tachycardia:
“Genetic analysis may help identify silent carriers of
catecholaminergic VT-related mutations; once identified
silent carriers may be treated with beta-blockers to reduce
the risk of cardiac events and may receive appropriate
genetic counseling to assess the risk of transmitting the
disease to offspring.”
Brugada Syndrome:
“Genetic analysis may help identify silent carriers of
Brugada syndrome-related mutations so that they
can remain under clinical monitoring to detect early
manifestations of the syndrome. Furthermore, once
identified, silent mutation carriers should receive genetic
counseling and discuss the risk of transmitting the disease to
offspring.”
Hypertrophic Cardiomyopathy:
"Genetic analysis is useful in families with HCM because whenever a pathogenic mutation is identified, it becomes possible to establish a presymptomatic diagnosis of the disease among family members and to provide them with genetic counseling to assess the risk of disease development and transmission of the disease to offspring. Genetic analysis may contribute to risk stratification in selected circumstances.”
For additional information, please contact
PGxHealth’s Customer Service team
at
877-2-PGxHealth
(877-274-9432)
or visit www.pgxhealth.com
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