Personalized Medicine

gene-testing program, but various initiatives are getting under way. Several insurance plans have implemented rules for covering certain genetic tests, such as the BRACAnalysis (Myriad Genetics) for breast cancer testing. Some plans have eligibility requirements or prior authorization protocols for the BRACA gene test, one that has the widest set of gene-testing programs in the industry. Another test for women with breast cancer, Oncotype DX (Genomic Health), an assay that is used to predict whether chemotherapy is likely be beneficial and whether the cancer is likely to recur. If the test result indicates that there is a good chance that the disease will return, the patient’s physician will need to prescribe drug treatment. These examples are isolated instances, and they are usually decided only once, when establishing policy. Using vendors, PBMs try to develop a comprehensive approach that covers all genetic tests. The new model will provide the framework for health plans to decide which tests they should cover, to ensure that the tests found to be valid are made available to patients, and to eliminate coverage for tests that are found to be less useful. Cancer represents an area in which genetic testing is going to be adopted quite rapidly over the next few years; several tests in development will be able to detect the risk of cancer and to indicate which drug regimens have a good chance of benefiting individual patients—and there will be increased opportunities for physicians and health plans to take advantage of these discoveries. In addition to testing for cancer, genetic testing may also become applicable for HIV infection and cardiovascular disease. In the coming years, there are likely to be more ways to predict genetic risk and select the appropriate pharmacotherapy.