Coverage of pharmacogenomic (PGx) testing is well underway in Canada. TELUS Health has contacted 10 insurance carriers and all offer at least one group insurance option, or have put in place a preferred-pricing arrangement. TELUS Health has pulled together a chart to summarize their offerings.
“The growing medical evidence seems to support the potential value of pharmacogenomic testing, particularly for members with mental health conditions,” said Maureen Long, assistant vice-president of group claims and administration, Equitable Life. “Ongoing use of this intervention will be required to measure the impact on both claims experience and employability for disability claimants.”
PGx testing, also referred to as pharmacogenetic testing, uses DNA from a saliva sample to assess how a person will respond to certain medications. Test results recommend which drugs would be most compatible based on the person’s unique genetic profile.
PGx testing is most likely covered as a disability benefit. Eight of the 10 insurers have included or will soon include the offering in the disability space: Canada Life, Equitable Life, Medavie Blue Cross, Pacific Blue Cross, SSQ Insurance and La Capitale (represented as one carrier in the chart, given their merger in July 2020) and Sun Life. Desjardins Insurance and Manulife will launch their disability benefit in the first quarter of 2021, and RBC Insurance has launched a pilot project to explore coverage in this space.
The details of coverage vary by carrier. For example, the disability case manager plays a central role for Canada Life and Pacific Blue Cross. Other insurers limit coverage to plan members with claims for certain health conditions, most often in the areas of mental health condition and pain.
Canada Life was the first to provide coverage, in December 2017, for a range of health conditions. “Case managers routinely determine whether pharmacogenetic testing would be appropriate based on the plan member’s circumstances, and if so coordinate directly with the patient, their physician and the testing provider,” said Ryan Weiss, vice-president, group customer product and experience, Canada Life.
Five insurers offer or will soon offer coverage of PGx testing as an extended health benefit (Desjardins, Green Shield Canada [GSC], Manulife, SSQ and Sun Life), and two are exploring this option (Medavie Blue Cross and Pacific Blue Cross).
In almost all cases, plan members can get coverage to test for drug compatibility for conditions in the areas of mental health, cardiovascular health, neurology (nervous system disorders), pain and attention deficit hyperactivity disorder (ADHD). GSC, which will launch its coverage in the first quarter of 2021, is targeting mental health conditions to start. Two insurers, Desjardins and Sun Life, require prescriptions from the member’s physician.
Three insurers have opted for preferred pricing arrangements with their testing provider in order to offer PGx testing at a discounted rate to plan members with extended healthcare coverage. RBC Insurance and Medavie Blue Cross have done so for some time, while Canada Life will launch its preferred pricing arrangement by the end of 2020.
Retail prices for PGx testing range from $300 to $500, depending on the test kit.
Preferred pricing may prove to be a stepping stone for Canada Life. “We found that plan sponsors weren’t universally ready to provide direct funding for this benefit until the technology continued to mature. Providing a direct-to-member approach was a way to balance this while still providing access,” said Weiss. “We hope to gain more insights and experience that can help inform whether we include coverage in extended health care benefits in the future,” said Weiss.
Similarly, Medavie Blue Cross is exploring whether to expand coverage to the extended health benefit plan, while RBC Insurance is exploring its coverage as a disability benefit.
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