The Maryland Health Care Commission (MHCC) seeks a Contractor to conduct an analysis which requires health insurers, nonprofit health service plans, and health maintenance organizations to require coverage for Pharmacogenomic Testing. Pharmacogenomic testing means laboratory genetic testing, including single-gene and multigene panel testing to evaluate how an individual’s genetic profile may impact the efficacy, safety, or toxicity of medications. The testing shall be covered if; the testing is ordered to treat a diagnosis of depression or anxiety; and the provider is considering a medication change, dose adjustment, or augmentation and the medication under consideration has known gene-drug interaction. Specifications include, but are not limited to: Scope of Work – Requirements; A. Evaluation of the Analysis to Require Coverage for Pharmacogenomic Testing. The Contractor shall utilize its health care actuaries’ knowledge and experience, proprietary databases, in-house data, carrier surveys, and other externally available data sources to complete this actuarial evaluation, that includes the following: 1. A social evaluation including: a) the extent to which the coverage and reimbursement requirement (or “the service”) is generally utilized by a significant portion of the population; b) the extent to which the insurance coverage is already generally available; c) the extent to which the lack of coverage results in individuals avoiding necessary health care treatments; d) the extent to which the lack of coverage results in unreasonable financial hardship; e) the level of public demand for the service; f) the level of public demand for insurance coverage of the service; and g) the extent to which the service is covered by self–funded employer groups of employers in the State who employ at least 500 employees. 2. A medical evaluation including: a) the extent to which the service is generally recognized by the medical community as being effective and efficacious in the treatment of patients; b) the extent to which the service is generally recognized by the medical community as demonstrated by a review of scientific and peer review literature; and c) the extent to which the service is generally available and utilized by treating physicians. 3. A financial evaluation including an estimate of both the marginal cost and the full cost of requiring carriers to provide this coverage and reimbursement requirement, including: a) the extent to which the coverage will increase or decrease the cost of the service; b) the extent to which the coverage will increase the appropriate use of the service; c) the extent to which the mandated service will be a substitute for a more expensive service; d) the extent to which the coverage will increase or decrease the administrative expenses of carriers, and the premium and administrative expenses of policy holders and contract holders; e) the impact of this coverage on the total cost of health care; and f) the impact of all mandated health insurance services on employers’ ability to purchase health benefits policies meeting their employees’ needs.
