Click on a state to see what Medicare Administrative Contractor (MAC) serves the state, which genetic tests are covered by the MAC, as well as the associated indication and non-covered indication for each non-medically necessary pharmacogenetic test.

Click here to see a list of PGX tests determined to be medically necessary for Medicare Coverage.

Note: The location of the laboratory running the test determines which MAC the test is covered under, which may be different than the MAC covering the state where patient lives or the MAC in which the test is ordered.

First Coast

Revision Effective Date: 10/1/2017
Genetic TestCoveredIndicationNon-covered Indications
CYP2C19YACS patients undergoing PCI initiating or reinitiating clopidogrel therapyConsidered investigational for (not limited to): amitriptyline, clopidogrel (for other indications than mentioned before), PPIs, SSRIs, and warfarin
CYP2D6YInitial therapy planned with: amitriptyline/nortriptyline (for depression) and tetrabenazine doses >50 mg/day or reinitiation of tetrabenazine doses >50 mg/dayConsidered investigational for (not limited to): antidepressants other than those listed previously, antipsychotics, codeine, donepezil, galantamine, tamoxifen
CYP2C9YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAll other coverage for genetic testing outside Coverage with Evidence Development (CED) standards is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to: celecoxib, flurbiprofen, and fluvoxamine
VKORC1YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsTesting for all medications outside the context of CED is considered investigational at this time. Available literature does not support that VKORC1 testing for all medications for drug responsiveness improves health outcomes in beneficiaries

Noridian

Revision Effective Date: 10/1/2017
Genetic TestCoveredIndicationNon-covered Indications
CYP2C19YACS patients undergoing PCI initiating or reinitiating clopidogrel therapyConsidered investigational for (not limited to): amitriptyline, clopidogrel (for other indications than mentioned before), PPIs, SSRIs, and warfarin
CYP2D6YInitial therapy planned with: amitriptyline/nortriptyline (for depression) and tetrabenazine doses >50 mg/day or reinitiation of tetrabenazine doses >50 mg/dayConsidered investigational for (not limited to): antidepressants other than those listed previously, antipsychotics, codeine, donepezil, galantamine, tamoxifen
CYP2C9YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAll other coverage for genetic testing outside CED standards is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to: celecoxib, flurbiprofen, and fluvoxamine
VKORC1YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsGenetic testing outside the context of CED for the VKORC1 gene is considered investigational at this time for all other medications.

Palmetto GBA

Revision Effective Date: 2/26/2018
Genetic TestCoveredIndicationNon-covered Indications
CYP2C19YACS patients undergoing PCI initiating or reinitiating clopidogrel therapyConsidered investigational for (not limited to): amitriptyline, clopidogrel (for other indications than mentioned before), PPIs, SSRIs, and warfarin
CYP2D6YInitial therapy planned with: amitriptyline/nortriptyline (for depression) and tetrabenazine doses >50 mg/day or reinitiation of tetrabenazine doses >50 mg/dayConsidered investigational for (not limited to): antidepressants other than those listed previously, antipsychotics, codeine, donepezil, galantamine, tamoxifen
CYP2C9YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAll other coverage for genetic testing outside CED standards is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to: celecoxib, flurbiprofen, and fluvoxamine
VKORC1YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsGenetic testing outside the context of CED for the VKORC1 gene is considered investigational at this time for all medications.

CGS Administrators

Revision Effective Date: 10/1/2017
Genetic TestCoveredIndicationNon-covered Indications
CYP2C19YACS patients undergoing PCI initiating or reinitiating clopidogrel therapyConsidered investigational for (not limited to): amitriptyline, clopidogrel (for other indications than mentioned before), PPIs, SSRIs and, warfarin
CYP2D6YInitial therapy planned with: amitriptyline/nortriptyline (for depression) and tetrabenazine doses >50 mg/day or reinitiation of tetrabenazine doses >50 mg/dayConsidered investigational for (not limited to): antidepressants other than those listed previously, antipsychotics, codeine, donepezil, galantamine, tamoxifen
CYP2C9YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAll other coverage for genetic testing outside CED standards is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to: celecoxib, flurbiprofen and fluvoxamine
VKORC1YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsGenetic testing outside the context of CED for the VKORC1 gene is considered investigational at this time for all medications.

Wisconsin Physicians Service Insurance Corporation

Revision Effective Date: 3/1/2018
Genetic TestCoveredIndicationNon-covered Indications
CYP2C19YACS patients undergoing PCI initiating or reinitiating clopidogrel therapyConsidered investigational for (not limited to): amitriptyline, clopidogrel (for other indications than mentioned before), PPIs, SSRIs, and warfarin
CYP2D6YInitial therapy planned with: amitriptyline/nortriptyline (for depression) and tetrabenazine doses >50 mg/day or reinitiation of tetrabenazine doses >50 mg/dayConsidered investigational for (not limited to): antidepressants other than those listed previously, antipsychotics, codeine, donepezil, galantamine, tamoxifen
CYP2C9YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAll other coverage for genetic testing outside CED standards is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to: celecoxib, flurbiprofen, and flovoxamine
VKORC1YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsGenetic testing outside the context of CED for the VKORC1 gene is considered investigational at this time for all medications.

National Government Services

Revision Effective Date: 1/1/2018
Genetic TestCoveredIndicationNon-covered Indications
CYP2C19YTo identify poor metabolizers of clopidogrel and poor metabolizers of clopidogrel with ACS or undergoing PCIMedically necessary once per lifetime
CYP2D6YHuntington's Disease patients being considered for tetrabenzine doses >50 mg/day and for testing prior to the initiation of eliglustat (Cerdelga) for Gaucher's disease
CYP2C9YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAll other coverage for genetic testing outside CED standards is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to: celecoxib, flurbiprofen, and fluvoxamine
VKORC1YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAvailable evidence does not demonstrate that pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness improves health outcomes in Medicare beneficiaries outside the context of CED

Novitas Solutions

Revision Effective Date: 3/8/2018
Genetic TestCoveredIndicationNon-covered Indications
CYP2C19YACS patients undergoing PCI initiating or reinitiating clopidogrel therapyConsidered investigational for (not limited to): amitriptyline, clopidogrel (for other indications than mentioned before), PPIs, SSRIs, and warfarin
CYP2D6YInitial therapy planned with: amitriptyline/nortriptyline (for depression) and tetrabenazine doses >50 mg/day or reinitiation of tetrabenazine doses >50 mg/dayConsidered investigational for: antidepressants other than those listed previously, antipsychotics, codeine, donepezil, galantamine, tamoxifen
CYP2C9YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAvailable evidence does not demonstrate that pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness improves health outcomes in Medicare beneficiaries outside the context of CED
VKORC1YWarfarin anticoagulation therapy candidates with: no previous testing for CYP2C9 or VKORC1 alleles, < 5 days of warfarin in anticoagulation regimen for which testing is ordered and enrollment in a prospective, randomized, controlled clinical study meeting NCD 90.1 standardsAvailable evidence does not demonstrate that pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness improves health outcomes in Medicare beneficiaries outside the context of CED