Is GeneSight® Covered by Insurance?

Finding the right mental health medication can take time, and for many, it’s a painful process of trial and error. GeneSight is a genetic test that helps doctors choose medications based on how your body is likely to respond, saving time, side effects, and setbacks.

But as with any medical test, one big question often comes up: is it covered by insurance?

Understanding how GeneSight coverage works, what factors affect it, and what to do if you’re paying out of pocket can help you make informed decisions.

What Is GeneSight Testing?

GeneSight is a genetic test that helps doctors select mental health medications based on how your body is likely to respond. It’s commonly used for conditions like depression, anxiety, and ADHD, especially when past medications haven’t worked well.

The test analyzes how your body metabolizes certain medications to identify options that may be more effective—and flag those that could cause side effects or be less helpful. 

It’s done with a quick cheek swab at your doctor’s office, and results usually return within 2 to 5 business days.

 

Is GeneSight Covered by Insurance?

The good news: many insurance plans do cover GeneSight. This includes Medicare, some Medicaid plans, and a range of private insurers. 

However, coverage depends on your specific plan and whether the test is considered “medically necessary.”

GeneSight is supported by clinical research and backed by thousands of success stories that show it can help improve medication selection and reduce unnecessary side effects 🛈. As a result, more insurance companies are beginning to include it in their coverage policies.

What Factors Affect Insurance Coverage?

Insurance coverage for GeneSight testing depends on several factors:

• Type of Insurance Plan: Medicare often covers the test. Coverage under Medicaid or private insurance varies by provider and state.
• Medical Necessity: Your doctor may need to document why the test is recommended for your treatment plan.
• In-Network Providers: Some insurance plans only cover services from providers or labs within their network. If your doctor or the lab processing the test isn’t in-network, you may face out-of-pocket fees.
• Pre-Authorization Requirements: Certain plans require prior approval before the test is performed. This means your doctor must get approval from the insurance company before ordering the test, or coverage may be denied.

If you’re not sure what your plan requires for GeneSight testing, ask your doctor’s office to help you check coverage, network status, or pre-authorization requirements. Even if your insurance won’t pay for the test, that doesn’t mean it’s out of reach.

What If GeneSight Isn’t Covered?

If your insurance doesn’t cover GeneSight, or only covers part of it, you may still be able to reduce the cost.

GeneSight testing is processed by Myriad Genetics. For patients without full coverage, Myriad offers:

• Financial assistance based on household income (typically under $75,000 for individuals).
• Out-of-pocket cost caps, with a maximum cost of around $330 for eligible patients.
• Interest-free payment plans to spread payments over time.

To find out what applies to you, ask your healthcare provider to reach out to Myriad’s billing support team.

Insurance Providers That Typically Cover GeneSight

GeneSight is commonly covered by plans from:

• Medicare
• Aetna
• Cigna
• UnitedHealthcare
• Humana
• Select Blue Cross Blue Shield plans
• Some state Medicaid programs

Keep in mind: coverage can vary even within the same insurance company, depending on your specific plan. Factors like whether your plan is through an employer, purchased individually, or part of a government program can all affect what’s covered.

How to Check If GeneSight Is Covered for You

To find out whether GeneSight testing is covered under your health insurance plan, follow these steps:

1. Consult Your Doctor

Ask your doctor if GeneSight is clinically appropriate for your situation. If they determine it’s necessary, they can submit the test order and any medical documentation your insurance may require.

2. Call Your Insurance Provider

Use the number on the back of your insurance card to speak with a representative. When you call, be ready to ask:

• “Is pharmacogenomic testing, including GeneSight, covered under my plan?”
• “Are there specific CPT codes I should reference for this test?” (GeneSight commonly uses CPT code 81225, among others.)
• “Is prior authorization required?”
• “Does my doctor or the lab need to be in-network for coverage to apply?”

Take notes during the call and ask for confirmation in writing, if possible.

3. Coordinate With Your Provider’s Office

Your doctor’s office, particularly the billing or prior authorization staff, can help submit the required paperwork to your insurance. This may include medical records showing that the test is medically necessary.

4. If Coverage Is Denied, Ask About the Appeals Process

If your insurance denies coverage:

• Request a written explanation of the denial.
• Ask your provider if they can submit an appeal with more detailed documentation.
• Every insurance company has an appeals process. Timelines and requirements can vary, so act quickly.

5. Explore Financial Assistance Options

If insurance won’t cover the test, you may still qualify for cost assistance or payment plans through Myriad Genetics. Your healthcare provider can connect with their billing team to check eligibility and estimate your out-of-pocket cost.

Where to Get GeneSight Testing

At Indiana Center for Recovery, we understand that mental health treatment isn’t one-size-fits-all. That’s why we offer tools like GeneSight testing as part of a broader, evidence-based approach to substance use treatment and mental health treatment.

Our team combines innovative tools like GeneSight testing with expert medical support, therapy, and compassionate care to develop a treatment plan that supports real, lasting progress.