PGxAI

Coverage & Insurance

Reimbursable Testing

Many pharmacogenomic (PGx) tests, including those offered through PGxAI, are recognized by major payors, and often covered under established CPT codes. This can significantly lower or eliminate out-of-pocket expenses for patients who meet certain clinical criteria.

How to Verify Coverage

1. Check Your Plan Review your insurance policy or contact your insurer’s customer service to confirm if PGx tests are included in your benefits.

2. Consult Your Provider Your doctor’s office or a participating clinic may already have an established billing process for PGx testing.

3. Inquire About Pre-Authorization Some plans require prior approval or specific documentation to qualify for coverage.

Billing & Claims Process

1. Streamlined Billing Your clinic or testing provider typically handles claim submissions, aligning each test with the relevant CPT codes for PGx.

2. Detailed Documentation PGxAI provides clear reports and rationale for recommended tests, supporting your case for insurance reimbursement.

3. Appeals & Support If a claim is initially denied, your provider or our support team can offer additional documentation or clarification to help overturn the decision.

Potential Out-of-Pocket Costs

1. Deductibles & Co-Pays Depending on your plan, you may have to pay a portion of the test cost until you meet your deductible.

2. Partial Coverage Some insurance plans only cover a percentage of PGx testing fees.

3. Flexible Spending Accounts (FSA/HSA) These funds can often be used to pay for any uncovered portion of your PGx test.

Why Coverage Matters

Wider Access to Precision Medicine Insurance coverage expands access to genomic insights, enabling more patients to benefit from targeted treatments.

Cost Savings By minimizing trial-and-error prescribing, PGx testing can reduce expensive medication missteps, hospital visits, and missed workdays.

Improved Health Outcomes Patients who receive the correct medication and dosage earlier often experience faster recovery and better long-term results.