The following is a summary of “Insurer coverage of prostate cancer biomarkers,” published in the July 2023 issue of the Urologic Oncology by Brant et al.
National guidelines recommend several recently developed prostate cancer (CaP) biomarkers, but their accessibility is unclear. Researchers analyzed insurance coverage for CaP biomarkers utilizing a national database. The policy reporter database was queried for insurance policies about 4K Score, ExoDx, My Prostate Score, Prostate Cancer Antigen 3, Prostate Health Index, and SelectMDx as of January 1, 2022. Coverage was determined based on whether a biomarker was regarded medically necessary, conditionally covered, or covered with prior authorization.
The Chi-square test was used to compare biomarker coverage rates by insurance type and geographic region. SelectMDx was excluded from the analysis because any queried policies did not cover it. Among 131 payers, a total of 186 insurance plans were identified. At least one biomarker was covered by 109 (59%) of the 186 plans, with prior authorization required for 38 (35%) of these plans. ExoDx, Prostate Health Index, and My Prostate Score had lower coverage rates than Prostate Cancer Antigen 3 and 4K Score (52% and 43% vs. 26%, 26%, and 5%, respectively, P<0.01). Medicare plans had higher coverage rates than non-Medicare plans (80% Medicare versus 17% commercial, 15% federal employer, and 13% Medicaid, P<0.01).
National programs had higher coverage rates than regional plans (43% national versus 32% midwest, 27% northeast, 25% south, 24% west, P<0.01). Biomarkers covered by Medicare plans were less likely to require prior authorization than those covered by non-Medicare plans (12% Medicare vs. 63% commercial, 100% federal employer, 70% Medicaid, P<0.01). Medicare plans cover novel CaP biomarkers to a greater extent than non-Medicare plans, with most non-Medicare plans requiring prior authorization. Men not qualifying for Medicare may encounter significant obstacles in obtaining these tests.