Medicare to Cover Breast Cancer Gene Sequencing: Coverage Updates

Managers of Medicare are copying the idea of a private company — Wamberg Genomic Advisors.

Wamberg Genomic Advisors has been marketing a stand-alone program that can help patients who are fighting just about any type of cancer “sequence,” or read, the DNA in the cancer, to give physicians ideas about how to target the cancer.

Officials at the Centers for Medicare and Medicaid Services (CMS) say that Medicare will be expanding its own DNA sequencing benefits.

Medicare first agreed to cover DNA sequencing for patients with advanced cancer in March 2018. Now, the program says it will add DNA sequencing coverage for patients who appear to be suffering from inherited ovarian cancer or inherited breast cancer.

Resources

• A copy of the Medicare sequencing coverage national coverage determination is available here.
• A copy of the formal coverage decision document is available here.
• An article about Wamberg Genomic Advisors’ DNA testing benefits program is available here.

Medicare will cover lab tests based on Next Generation Sequencing technology that are approved or cleared by the federal Food and Drug Administration, CMS officials say.

CMS uses private companies, or “Medicare administrative contractors,” to run the Original Medicare program. The administrative contractors will have the discretion to cover DNA testing for patients not specifically described in the 2018 national coverage determination or in the new national coverage determination.

CMS Administrator Seema Verma said in a statement about the new Medicare benefits that innovative technologies are transforming medicine.

“At every turn, President Trump has shown a dogged determination to give Americans access to them,” Verma said.  “We recognize that cancer patients shoulder a heavy burden, so we’re leaving no stone unturned in supporting women’s health and getting all patients the care they need.”

In addition to helping patients get better-targeted treatment, DNA sequencing may help patients participate in clinical trials, or chances to try drugs that have not yet been approved for general use, officials say.

In other coverage update news, Capital Rx Inc., a pharmacy benefit manager based in New York, has formed a relationship with Schraft’s 2.0, a fertility drug pharmacy.

Capital Rx says the deal will help it push the cost of an in vitro fertilization for a health plan member below the current $22,000-per-cycle average.

The plan sponsor can choose whether to pay some, none or all of the cost, Capital Rx says.

Fifteen states now have fertility services insurance benefits mandates, but those mandates vary widely from state to state, Capital Rx says. In many cases, the PBM says, employers and insurers still can decline to fertility treatments.

One drawback of offering weak fertility benefits is that plan members may choose cheaper, riskier fertility treatments, Cap Rx says.

One relatively inexpensive fertility treatment increases the odds that patients will have triplets — and the odds that a plan will have to spend hundreds of thousands of dollars on triplet care, Cap Rx says.

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