Will Insurance Cover the Cost of the Oncotype DX® Test?

Does Health Insurance Cover the Cost of the Oncotype DX® Test?

Insurance cover the cost of the oncotype dx testIt’s no doubt that the Oncotype DX test can be one of the most beneficial tests to take during early diagnosis. It can give you critical information that may change the course of your breast cancer journey. But can your insurance cover the cost of the Oncotype DX® Test?

This has been a question many of our viewers have asked us, and rightfully so. Results can give you treatment information, including if chemotherapy is right for you type of cancer. Not only does this test personalize your treatment, it can even let you know about the likelihood of breast cancer recurrence.

Find out from our Medical Director Dr. Jay Harness if your insurance can cover your Oncotype DX test.


Jay K. Harness: When I ordered the Oncotype DX test, my patients are naturally concerned whether their insurance will cover the cost of the test. Let me go through the individual indications for the test and then address the issue of insurance coverage. The most common breast cancer in the United States is estrogen receptor positive lymph node negative breast cancer. NCCN Guidelines call for the use of the Oncotype DX test in set of circumstances, Medicare fully covers the cost of the test and virtually all the major insurance carriers also cover the cost of the test and estrogen receptor positive lymph node negative breast cancer patients. The second indication in my practice and most all that I know is the indication for estrogen receptor positive lymph node positive breast cancers. Here, we are talking about anywhere from one up to three positive lymph nodes. Once again, this is not covered under NCCN Guidelines and also by Medicare. The NCCN Guidelines are the kind of guidance that insurance companies use to determine whether they’re going to pay for things in the world of cancer treatment. The coverage by insurance carriers other than Medicare in lymph node positive patients varies, but on appeal virtually most all the time this is covered and rarely when a patient have to bear the cost on a personal basis. There are mechanisms for handling it the coverage of the test if an insurance company for whatever reason decides to turn it down. Now, the most recent indication for the Oncotype test is in situ breast cancer, ductal carcinoma in situ DCIS and here many of the insurance companies have not officially embraced this. However, they are able to cover the cost of the Oncotype test and DCIS under umbrella coverages that they have for lymph node negative invasive breast cancer, so in the vast majority of cases, you don’t have to worry about the insurance coverage for the Oncotype DX test. There are appeal mechanisms, the company of course works with individuals and in my experience almost rarely is the coverage not provided or rarely does the patient have to cover the cost themselves.