Medicare AdvantageCoverageMedium impact
Pharmacogenomics Testing - Medicare Advantage (Revised)
Humana·Pharmacy·Pharmacy
Effective date
Aug 3, 2026
We identified it
Aug 4, 2026
Summary
Humana Medicare Advantage has updated its Pharmacogenomics Testing policy (effective 08/03/2026) to clarify coverage requirements across multiple MAC jurisdictions. The policy establishes that pharmacogenomics testing is covered only when ordered by a treating physician, meets clinical validity standards, and demonstrates clinical utility for specific medical problems—not for screening or risk assessment. Billing teams must verify MAC-specific LCD/LCA requirements by geographic jurisdiction before processing claims.
Action Required
By August 3, 2026: Billing team must implement jurisdiction-specific coverage verification for pharmacogenomics testing claims based on applicable MAC (MolDX, Wellpoint Federal, CGS, Noridian, Novitas, Palmetto GBA, or First Coast Service Options). Before submitting claims: (1) Identify the member's MAC jurisdiction from the Related CMS Documents table; (2) Review the applicable LCD/LCA for that jurisdiction to confirm coverage criteria; (3) Verify prior authorization requirements per MAC guidelines; (4) Confirm test is ordered by treating physician for diagnosis/treatment of a specific medical problem (not screening, risk assessment, or diagnosis confirmation); (5) Deny or request medical necessity documentation for tests lacking diagnosis-specific indications. Update encounter forms and billing software logic to flag pharmacogenomics testing for manual review per MAC jurisdiction. Claims submitted without proper MAC jurisdiction verification or lacking diagnosis-specific medical necessity will be denied.