Insurance Forms

Aetna

AETNA requires that a medical precertification (prior authorization) be obtained before testing for BRCA genes and whole exome sequencing (WES) tests can be started at a laboratory. Therefore, GeneDx will not initiate testing on any samples submitted with AETNA health insurance plans for WES-based tests (XomeDx®, XomeDx®Slice, Xpanded panels) or tests that include the BRCA1 and/or BRCA2 genes until an AETNA medical precertification (prior authorization) is approved.

To view and download the AETNA Medical Precertification forms for BRCA or WES, please visit https://www.aetna.com/health-care-professionals/health-care-professional-forms.html and scroll down to Medical Precertification. Then, expand the section and click to download the needed 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

 

United Healthcare (UHC)

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.

*PLEASE NOTE: If ordering hereditary cancer testing for a patient covered by United Healthcare insurance, please click here to view an important order process notification.*

UHC BRCA Prior Authorization 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
Medicare Guidelines – BRCA1/BRCA2 Genetic Testing
ABN Form
Spanish ABN Form