Insurance Forms

Aetna

The Aetna Prior Authorization form must be filled out and signed by the order physician and sent along with the requisition. This form is only required for tests that include the BRCA1 and/or BRCA2 genes; see below:

B361 BRCA1/2 Ashkenazi Founder Mutation Panel
B362 BRCA1/2 Sequencing and Deletion/Duplication
B502 BRCA1/2 Sequencing
B501 BRCA1/2 Deletion/Duplication (Only if Aetna Medicare)
B275 Comprehensive Cancer Panel
B751 High/Moderate Risk Panel
B521 Breast Cancer High Risk Panel
B273 Breast/Ovarian Cancer Panel
B343 Pancreatic Cancer Panel
B344 Endometrial Cancer Panel
B749 OncoGeneDx Custom Panel (Only when BRCA1 or BRCA2 are selected)
B370-8 Testing for a previously identified familial mutation or variant (Only when BRCA1 or BRCA2 are ordered)
Aetna Prior Authorization Form 


Cigna

Cigna requires their cigna genetic counseling recommendation form be filled out for all hereditary oncology syndromes, hereditary cardiomyopathies and arrhythmias, whole genome array/chromosomal microarray (CMA) and whole exome sequencing (WES).  This form has to be completely filled out by a GCN, APNG, or board certified Genetic Counselor. To find a local Genetic Genetic Counselor, please visit the NSGC website: www.nsgc.org or you can get a referral from InformedDNA.

Cigna Genetic Counseling Recommendation Form
WES Cigna Genetic Counseling Recommendation Form
InformedDNA Form GC Referral Form

UHC (United Healthcare)

Starting January 1, 2016 UHC will require a prior authorization form for BRCA testing to be filled out for genetic testing.  This form has to be completely filled out by the following:

  • Genetic Counselor
  • Advanced Genetics Nurse
  • Genetic Clinical Nurse
  • Advanced Practice Nurse in Genetics
  • A board-eligible or board-certified clinical geneticist
  • A physician with experience in cancer genetics (defined as providing cancer risk assessment on a regular basis and having received specialized ongoing training in cancer genetics. Educational seminars offered by commercial laboratories about how to perform genetic testing are not considered adequate training for cancer risk assessment and genetic counseling).

To find a local Genetic Genetic Counselor, please visit the NSGC website: www.nsgc.org or you can get a referral from InformedDNA.

UHC BRCA Prior Authorization Form
InformedDNA Form GC Referral Form


Medicare

A completed Advance Beneficiary Notice (ABN) is required for patients that do not meet Medicare criteria. In addition, please include a signed informed consent.

Medicare Criteria Form
ABN Form
Spanish ABN Form