Coverage of Conditions and Treatments (Coverage Decisions)

Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.

List also available in PDF format.

Archived Coverage Decisions.

See Treatment Guidelines and Resources for additional information.

Pharmacogenomic testing is also known as pharmacogenetic testing or drug-gene testing. It looks for changes or variants in a person’s genes that may determine whether a medication could be an effective treatment for them or whether they could have side effects to a specific medication. The safety and efficacy of such testing must be researched for each type of medication, each with its own coverage decision. What follows is a list of those decisions made to date by Washington State’s Health Technology Clinical Committee (HTCC); first, for selected psychiatric conditions, and recently for oral anticoagulants.

Pharmacogenomic testing for selected psychiatric conditions

Coverage Decision: Not Covered (Effective date: July 1, 2017)

The HTCC determined that pharmacogenomic testing for depression, mood disorders, psychosis, anxiety, attention deficit/hyperactive disorder (ADHD) and substance use disorder is not a covered benefit. The committee reviewed the evidence on pharmacogenomic testing for selected conditions in January 2017, and found the technology unproven for safety, efficacy and cost-effectiveness based on the quality of available evidence. The committee finalized the decision in March 2017.

Pharmacogenomic testing for patients being treated with oral anticoagulants

Coverage Decision: Not Covered (Effective date: November 1, 2018)

The HTCC determined that pharmacogenetic testing for patients being treated with oral anticoagulants is not a covered benefit. The committee reviewed the evidence on pharmacogenomic testing for selected conditions in May 2018 and found the technology unproven for safety, efficacy and cost-effectiveness based on the quality of available evidence. The committee finalized the decision on July 13, 2018.

In adopting these HTCC coverage determinations, the Department has concluded that the determinations do not conflict with any state statute. Any coverage for investigational treatment would be considered per WAC 296-20-02850. Any coverage for health technologies that have a FDA Humanitarian Device Exemption status would be considered per RCW 70.14.120 (1) (b).

Other conditions: L&I does not cover pharmacogenomics (pharmacogenetic) testing for any other conditions.