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Partnering with You & Your Patients

Exact Sciences believes that everyone should have access to the information they need to make confident, informed decisions about their cancer treatment.

Genomic Access Program

To advance this mission, we created the Genomic Access Program (GAP) to help patients navigate and understand the insurance and billing process for the Oncotype tests. GAP assists with obtaining prior authorizations, billing insurance, appealing denied claims and providing flexible payment options when necessary. Learn more

Insurance Coverage

The Oncotype tests are covered by Medicare and many commercial insurance plans and is available to patients who are enrolled in a Medicaid program. Exact Sciences* is an in-network provider with many health plans, including Aetna, Anthem, Cigna, Humana and UnitedHealthcare. Exact Sciences performs the services ordered and deemed medically necessary, regardless of network-provider status.

Look Up In-Network Plans for Oncotype Tests

Select the region on the map to see if the Oncotype tests are in-network for a specific plan

West

Payor State
Aetna National
Anthem Blue Cross and Blue Shield in Colorado CO
Anthem Blue Cross and Blue Shield in Nevada NV
Anthem Blue Cross of California CA
Blue Cross and Blue Shield of Montana MT
Blue Cross and Blue Shield of New Mexico NM
Blue Cross Blue Shield of Arizona AZ
Blue Cross Blue Shield of Wyoming WY
Blue Cross of Idaho ID
Blue Shield of California CA
Bright Health Plan AZ, CO
Centene - Arizona Complete Health (Ambetter and Allwell) AZ
Centene - Health Net of CA (Commercial Exchange and Medicare Advantage) CA
Centene - Coordinated Care (Ambetter and Allwell) WA
Centene - Trillium Community Health Plan (Med Adv) OR
Centene - Health Net Health Plan of Oregon (Med Adv) OR
Centene - SilverSummit Health Plan (Ambetter) NV
Cigna National
Contra Costa Health Plan CA
Coquille Tribe OR
Culinary Health Fund NV
Health Net Federal Services, LLC (TRICARE West Region)* AK, HI, WA, OR, CA, ID, NV, UT, CO, AZ, NM, MT, WY
Health Plan of Nevada NV
HMSA HI
Hometown Health NV
Humana National
Kaiser Foundation Health Plan of Washington ID, WA
Moda Health OR
Molina Healthcare CA, NM, WA, UT, ID
Mountain Health CO-OP ID, MT
New Mexico Health Connections NM
Oscar Health Insurance AZ, CA, CO
PacificSource Health Plans OR, ID, MT
Prominence Health Plan NV
Providence Health Plan OR
Public Employees Health Plan (PEHP) UT
Regence BlueCross BlueShield of Oregon OR
Regence BlueCross BlueShield of Utah UT
Regence BlueShield of Idaho ID
Regence BlueShield of Washington WA
Rocky Mountain Health Plan CO
Scripps Health Plan Services CA
SelectHealth ID, NV, UT
Sierra Health and Life NV
United Healthcare National
United Medical Resources (UMR) National
University of Utah Health Plans UT, ID

Midwest

Payor State
Aetna National
Anthem Blue Cross and Blue Shield – Indiana IN
Anthem Blue Cross and Blue Shield – Missouri MO
Anthem Blue Cross and Blue Shield – Ohio OH
Anthem Blue Cross and Blue Shield – Wisconsin WI
Arise Health Plan/WPS Health Insurance WI
Aultcare OH
Avera Health Plans, Inc. SD
Blue Cross and Blue Shield of Illinois IL
Blue Cross and Blue Shield of Kansas KS
Blue Cross and Blue Shield of Kansas City KS, MO
BlueCross BlueShield of Michigan and Blue Care Network of Michigan (JVHL BCN Participating Provider) MI
BlueCross BlueShield of Nebraska NE
Blue Cross & Blue Shield of Minnesota MN
Blue Cross Blue Shield of North Dakota ND
Blue Cross Blue Shield of Texas TX
Bright Health Plan IL, OH, OK, NE
Care N Care Health Plan TX
CareSource Indiana IN
Centene - IlliniCare (Ambetter and Allwell) IL
Centene - MHS (Ambetter and Allwell) IN
Centene - Sunflower Health Plan (Ambetter and Allwell) KS
Centene - Buckeye Health Plan (Ambetter and Allwell) OH
Centene - Superior Healthplan (Ambetter and Allwell) TX
Centene - MHS Health Wisconsin (Allwell) WI
Centene - Home State Health (Ambetter and Allwell) MO
Centene - Arkansas Health & Wellness (Ambetter and Allwell) AR
Cigna National
Common Ground Healthcare Cooperative WI
Dean Health Plan/Prevea360 Health Plan WI
Global Health OK
Group Health Cooperative Eau Claire WI
Group Health Cooperative of South Central WI WI
Health Alliance Medical Plans, Inc. IL
Health Alliance Plan of Michigan MI
Health Net Federal Services, LLC (TRICARE West Region)* TX, KS, MO, IA, NE, NM, ND, SD
HealthChoice OK
HealthPartners MN, IA, WI
Health Tradition Health Plan WI
Humana National
IdealCare by Sendero Health Plans TX
Indiana University Health Plans IN
McLaren MI
Medica Health Plans MN, IA, KS, NE, ND, SD, WI
Medical Associates Health Plan IA, IL, WI
Medical Mutual of Ohio OH
MercyCare Health Plan WI, IL
MHS Wisconsin WI
Molina Healthcare MI, OH, TX, WI
Network Health WI
Ohio State University Health Plan OH
Oscar Health Insurance KS, MO, MI, TX, OH
Physicians Health Plan of Northern Indiana IN
Physicians Health Plan MI
Physicians Plus WI
Preferred Health Choice IA, IL, WI
Preferred One MN
Priority Health MI
Prominence Health Plan TX
Quad City Community Healthcare IA
Sanford Health Plan SD
SummaCare OH
Total Healthcare MI
United Healthcare National
United Medical Resources (UMR) National
Unity Health Plan WI
WEA Trust WI
Wellmark Blue Cross and Blue Shield of Iowa IA
Wellmark Blue Cross and Blue Shield of South Dakota SD

Northeast

Payor State
1199SEIU NY
Aetna National
Agewell NY
AllWays Health Partners, Inc. (fka Neighborhood Health Plan) MA
Amerihealth New Jersey NJ
Anthem Blue Cross and Blue Shield – Connecticut CT
Anthem Blue Cross and Blue Shield – Maine ME
Anthem Blue Cross and Blue Shield – New Hampshire NH
Beacon Health ME
Blue Cross & Blue Shield of Massachusetts MA
BlueShield of Northeastern New York NY
BlueCross BlueShield of Western New York NY
Blue Cross & Blue Shield of Rhode Island RI
Blue Cross and Blue Shield of Vermont VT
Bright Health Plan NY
Capital BlueCross (Participates in the Avalon Healthcare Solution network of laboratories) PA
Capital District Physicians’ Health Plan NY
Centene - New Hampshire Health Families (Ambetter) NH
Centene - PA Health & Wellness (Ambetter and Allwell) PA
Cigna National
ConnectiCare, Inc. MA, RI, NY, CT
EmblemHealth NY
Empire BlueCross BlueShield NY
Excellus BlueCross BlueShield NY
Fallon Community Health Plan MA
Fidelis Care NY
Gateway Health Plan – HealthChoices (Med Adv) PA
Geisinger Health Plan PA
Harvard Pilgrim Health Plan MA
Health New England CT, MA
Healthfirst NY
Healthsmart World Trade Center Health Plan NY
Highmark Blue Cross and Blue Shield PA, WV, DE
Horizon Blue Cross Blue Shield of New Jersey NJ
Humana National
Independent Health Association NY
Maine Community Health Options ME
Molina Healthcare NY
Neighborhood Health Plan of Rhode Island RI
Oscar Health Insurance NY, NJ
Partners Health Plan NY
Tufts Health Plan MA, RI, NH
United Healthcare National
United Medical Resources (UMR) National
Univera Healthcare NY
UPMC PA
US Family Health Plan of New York NY

Mid-Atlantic

Payor State
Aetna National
Anthem Blue Cross and Blue Shield – Kentucky KY
Anthem Blue Cross and Blue Shield in Virginia (PPO only; HMO Healthkeepers/‌Healthkeepers Plus must obtain in-network exception) VA
BlueCross BlueShield of North Carolina (Participates in the Avalon Healthcare Solution network of laboratories) NC
BlueCross BlueShield of Tennessee TN
Bright Health Plan NC, TN
CareFirst BlueCross BlueShield DC, MD, VA
Centene - Ambetter of Tennessee TN
Centene - Ambetter of North Carolina Inc. NC
Cigna National
FirstCarolinaCare NC
Highmark Blue Cross and Blue Shield PA, WV, DE
Humana National
Johns Hopkins Employer Health Programs MD
Johns Hopkins US Family Health Plan MD
MedStar Family Choice MD
Optima Health VA
Oscar Health Insurance TN, VA, PA
Piedmont Community Health Plan VA
Sentara Health Plan VA
United Healthcare National
United Medical Resources (UMR) National
Virginia Premier VA

South

Payor State
Aetna National
Blue Cross & Blue Shield of Florida FL
Blue Cross and Blue Shield of Georgia, Inc. (PPO only; HMO/Open Access POS must obtain in-network exception) GA
Blue Cross & Blue Shield of Louisiana LA
BlueCross BlueShield of Alabama AL
BlueCross BlueShield of South Carolina (Participates in the Avalon Healthcare Solution network of laboratories) SC
Bright Health Plan AL, FL, GA, SC
Centene - Sunshine Health (Ambetter and Allwell) FL
Centene - Peach State Health Plan (Ambetter and Allwell) GA
Centene - Louisiana Healthcare Connections (Allwell) LA
Centene - Magnolia Health (Ambetter and Allwell) MS
Centene - Absolute Total Care (Ambetter and Allwell) SC
Cigna National
Florida Health Care Plans, Inc. FL
Health First Health Plan FL
Humana National
Molina Healthcare FL
MS State and School Employees' Health Insurance Plan MS
Oscar Health Insurance FL, GA
United Healthcare National
United Medical Resources (UMR) National

Last updated April 2021. This is not an exhaustive list as plans are being added regularly.†

Genomic Access Program

It starts with you...and we take it from there

Order the Oncotype Test

Ordering an Oncotype test and receiving the results is a straightforward process.

Online Ordering

For faster results, complete your requisition form online on the Physician Portal as insurance can be verified and most required forms can be pre-filled and completed online.

If you do not have an online ordering account, sign up today.

Necessary Information

Be sure to include a copy of your patient’s insurance card and the primary ICD-10 code selection supporting medical necessity. When ordering for your Medicare patients, please include the Specimen Collection Date and Patient Hospital Status to streamline the process.

Verify & Bill Insurance

The billing process starts with performing insurance verification for each patient using the insurance information provided when the test is ordered.

Prior Authorizations

We obtain prior authorizations, when required by the payer, using the documentation provided by your office on the completed requisition form. The insurance information you provide helps us determine whether prior authorization or other forms are required by the insurance company. We will contact your office with instructions if the payer requires that the physician initiate the Prior Authorization or asks for additional documentation from your office.

Explanation of Benefits

Once Oncotype testing is complete, we handle insurance billing on behalf of your patients when this option is selected on the requisition form. Patients may receive one or more Explanation of Benefits (EOB) from their insurance company. Even though this is not a bill, we are here to answer any questions patients may have.

Offer Financial Assistance

Assistance with Appeals

If the claim is denied, we will pursue appeals on the patient’s behalf if appeal options are available. This process can take several months.

Out-of-Pocket Payment Options

Out-of-pocket (OOP) costs for the test, if any, are determined by the insurance company. Patients may have financial responsibility for a co-pay, co-insurance, deductible or non-covered charges as determined by their insurance plan once available appeal options are completed. If your patient’s out-of-pocket amount exceeds $500, they will receive a call to discuss payment options. We will also submit secondary or supplemental insurance claims on your patient’s behalf if the necessary information was submitted with the order. If your patient receives a bill and is not sure if a claim was submitted to their secondary or supplemental insurance, please have your patient contact us.

Financial Assistance

Financial assistance is available for eligible patients who are uninsured and may be available for insured patients unable to pay the out-of-pocket amount determined by their insurance.

  • Eligibility is based on Federal poverty guidelines, and we proactively contact all uninsured patients to determine eligibility for financial assistance. Payment plans may also be available.
  • Patients may also contact us before the test is ordered or during the testing process to review available payment terms or to be pre-screened‡ for financial assistance.
  • Financial assistance is not available if the patient has insurance coverage but elects to be billed directly instead of billing insurance.

Because insurance coverage varies across the country and is based on medical policy and benefit design, it is sometimes difficult for patients to understand costs associated with testing. We strongly encourage patients to contact their insurer when they have questions about their plan design and benefits.

Medicare Information

Oncotype tests are covered by Medicare Fee for Service (FFS) for patients meeting coverage criteria. Patients who meet clinical criteria for coverage have zero financial responsibility. See the specific coverage criteria for each Oncotype test

Advance Beneficiary Notice (ABN) Requirements

Medicare FFS requires that providers give their Medicare patients an ABN form before they receive any services not considered medically necessary under the Medicare FFS program. This is required because the patient will be responsible for paying for the test if they still choose to receive it.

The 14-Day Rule

Medicare FFS has specific date of service reporting requirements for laboratory tests, and the technical component of physician pathology services, ordered for Medicare patients (commonly known as the “14-Day Rule”). The 14-Day Rule determines whether the laboratory performing the test bills Medicare directly or bills the hospital where the specimen was collected.

In general, Medicare requires that laboratories bill the hospital when the test is ordered less than 14 days following a patient’s inpatient or outpatient hospital stay (when the specimen was collected). However, as of January 1, 2018, the 14-day rule does not apply to molecular pathology tests when the specimen is collected from a hospital outpatient, regardless of order date.

We process test orders as they are received from providers. Clinical judgment should be the determining factor for test ordering.

Resources

Helpful documents to download

Learn more about billing and coverage for each Oncotype test

Oncotype DX AR-V7 Nucleus Detect
Oncotype DX Breast DCIS Score
Oncotype DX Breast Recurrence Score
Oncotype DX Colon Recurrence Score
Oncotype DX Genomic Prostate Score
Oncotype MAP Pan-Cancer Tissue

Medicare Coverage Criteria

Oncotype DX AR-V7 Nucleus Detect Assay

Local Coverage Determination (LCD): MolDX: Androgen Receptor Variant (AR-V7) Protein Test (L37701)

See the full LCD

Coverage Indications, Limitations, and/or Medical Necessity

This contractor will provide limited coverage for an Androgen Receptor splice variant 7 messenger RNA protein test (AR-V7) to help determine which patients with metastatic castrate resistant prostate cancer or other androgen receptor containing tumors may benefit from androgen receptor signaling inhibitor therapy and which may benefit from chemotherapy.

AR-V7 is covered as follows:

  • Patients will have progressive mCRPC as defined by the Prostate Cancer Working Group 2 guidelines (a minimum of 2 rising prostate-specific antigen (PSA) levels 1 or more weeks apart, new lesions by bone scintigraphy, and/or new or enlarging soft tissue lesions by computed tomography (CT) or magnetic resonance imaging (MRI)).
  • Patients will have failed one ARSi, (presently Enzalutamide (Xtandi), Apalutamide (Erleada), or Abiraterone (Zytiga) and future similar class drugs approved by the FDA) .
  • Patients will be considered appropriate for treatment by their treating physician for the alternative ARSi as a single agent.
  • Circulating tumor cells (CTC) with nuclear expression of AR-V7 protein will be assessed prior to initiation of therapy.
  • Decision impact analysis: We expect that < 15% of nuclear AR-V7-positive patients will receive an ARSi.
  • Efficacy analysis: Nuclear AR-V7-negative patients who receive an ARSi will have similar or better time on therapy than untested mCRPC patients (meeting above criteria) receiving an ARSi.
  • Other Androgen Receptor variant tests that demonstrate an equivalent analytical validity and clinical validity will be considered reasonable and necessary for similar diagnoses and criteria listed below indications. Analytical and clinical validity will be assessed as part of a thorough and comprehensive technical assessment (TA) by the MolDx program and will similarly attain coverage for indications that are supported by the evidence and intended use within the scope of this policy.
Oncotype DX Breast DCIS Score Assay

Local Coverage Determination (LCD): MolDX: Oncotype DX Breast DCIS Score Assay (Genomic Health) (L36941)

See the full LCD

The Oncotype DX Breast DCIS Score assay is covered only when the following clinical conditions are met:

  • Pathology (excisional or core biopsy) reveals ductal carcinoma in situ of the BREAST (no pathological evidence of invasive disease), and
  • FFPE specimen with at least 0.5 mm of DCIS length, and
  • Patient is a candidate for and is considering BREAST conserving surgery alone as well as BREAST conserving surgery combined with adjuvant radiation therapy, and
  • Test result will be used to determine treatment choice between surgery alone vs. surgery with radiation therapy, and
  • Patient has not received and is not planning on receiving a mastectomy.
Oncotype DX Breast Recurrence Score Assay

Local Coverage Article: Billing and Coding: MolDX: Oncotype DX Breast Recurrence Score Cancer Assay (A54480)

Oncotype DX Breast Recurrence Score test was developed for patients with the following findings:

  • estrogen-receptor positive, node-negative carcinoma of the BREAST
  • estrogen-receptor positive micrometastases of carcinoma of the BREAST, and
  • estrogen-receptor positive BREAST carcinoma with 1-3 positive nodes
Oncotype DX Colon Recurrence Score Assay

Local Coverage Article: Billing and Coding: MolDX: Oncotype DX Colon Recurrence Score Assay (A54484)

The Oncotype DX Colon Recurrence Score test, developed to predict the recurrence risk for patients with Stage II COLON CANCER.

Oncotype DX Genomic Prostate Score Assay

Local Coverage Determination (LCD): MOLDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (L38339)

See the full LCD

Coverage Indications, Limitations, and/or Medical Necessity

This is a limited coverage policy for Genomic derived tests that assess risk in localized (non-metastatic) prostate cancer. The test is considered reasonable and necessary to help identify men with localized Prostate Cancer and a life expectancy of at least 10 years who are good candidates for active surveillance according to the most recent National Comprehensive Cancer Network (NCCN) guidelines.

Covered for men with prostate cancer:

With localized or biochemically recurrent adenocarcinoma of the prostate (i.e., no clinical evidence of metastasis) who have a life expectancy of greater than or equal to 10 years if they are a candidate for and are considering (or being considered for) at least 1 of the following:

  • Conservative management and yet would be eligible for definitive therapy (radical prostatectomy (RP), radiation or brachytherapy), or;
  • Radiation therapy and yet would be eligible for the addition of a brachytherapy boost, or;
  • Radiation therapy and yet would be eligible for the addition of short-term androgen deprivation therapy (ADT), or;
  • Radiation therapy with short-term ADT yet would be eligible for the use of long-term ADT, or;
  • Radiation with standard ADT yet would be eligible for systemic therapy intensification using next generation androgen signaling inhibitors or chemotherapy, or;
  • Observation post-prostatectomy yet would be eligible for the addition of post-operative adjuvant radiotherapy, or;
  • Salvage radiotherapy post-prostatectomy yet would be eligible for the addition of ADT.

The following criteria must also be met for coverage:

  • The assay is performed on formalin-fixed paraffin embedded (FFPE) prostate biopsy tissue with at least 0.5 mm of linear tumor diameter or FFPE tissue from a prostate resection specimen, and;
  • Result will be used to determine treatment according to established practice guidelines, and;
  • Patient has not received pelvic radiation or ADT prior to the biopsy or prostate resection specimen, and;
  • Patient is monitored for disease progression according to established standards of care.

Other genomic tests that demonstrate an equivalent analytical validity and clinical validity will be considered reasonable and necessary for the same indications. Analytical and clinical validity will be assessed as part of a thorough and comprehensive technical assessment (TA) by the MolDX program and will similarly attain coverage for indications that are supported by the evidence and intended use within the scope of this policy.

Oncotype MAP Pan-Cancer Tissue Assay

Local Coverage Determination (LCD): MolDX: Next-Generation Sequencing for Solid Tumors (L38119)

See the full LCD

Criteria for Coverage

All the following must be present for coverage eligibility:

As per NCD 90.2, this test is reasonable and necessary when the patient has either:

  • Recurrent cancer
  • Relapsed cancer
  • Refractory cancer
  • Metastatic cancer
  • Advanced cancer (stages III or IV)
  • AND has not been previously tested by the same test for the same genetic content
  • AND is seeking further treatment

The test has satisfactorily completed a technical assessment by MolDX for the stated indications of the test. The assay performed includes at least the minimum genes and genomic positions required for the identification of clinically relevant FDA-approved therapies with a companion diagnostic biomarker as well as other biomarkers known to be necessary for clinical decision making for its intended use that can be reasonably detected by the test. Because these genes and variants will change as the literature and drug indications evolve, they are listed separately in associated documents such as the MolDX TA forms.

FOOTNOTES

* Genomic Health, Inc., an Exact Sciences company, is the billing entity for Oncotype tests.

† This list includes parent companies and their subsidiaries. This list is subject to change. It is not intended to be a directive, nor is it a suggestion about the likelihood of coverage or reimbursement. Exact Sciences Corporation and its affiliates (Exact Sciences) makes no representation or warranty regarding this information or its completeness, accuracy, timeliness or applicability with any particular patient. Reimbursement information provided herein is gathered from 3rd party sources and is presented for informational purposes only. This information does not constitute legal or reimbursement advice. Exact Sciences specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on information provided on this site. Providers are responsible for making appropriate decisions related to coding and reimbursement submissions. Accordingly, Exact Sciences recommends that customers and patients consult with their payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters.

‡ Pre-screening does not guarantee qualification or disqualification, since a patient’s financial circumstances may change during or after testing.

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