MEDICAL POLICY 12.04.515
Genetic Testing for Mental Health Conditions
BCBSA Ref. Policy: 2.04.110
Effective Date: Aug. 1, 2017
Last Revised: Jan. 30, 2018
Replaces: 2.04.110
RELATED MEDICAL POLICIES:
12.04.131 Pharmacogenetic Testing for Pain Management
Select a hyperlink below to be directed to that section.
POLICY CRITERIA | CODING | RELATED INFORMATION
EVIDENCE REVIEW | REFERENCES | HISTORY
Clicking this icon returns you to the hyperlinks menu above.
Introduction
Genetic testing is done to see if there are changes in chromosomes, genes, or the proteins made
by genes. There are many reasons to do a genetic test, such as to confirm or rule out a genetic
condition, to determine the chance of developing or passing on a genetic disorder, or to see if a
person has an increased risk of having health problems. When it comes to mental health,
genetic tests generally try to determine if a person is at risk for a condition such as
schizophrenia. Other mental health genetic tests try to find out a persons response to a certain
drug or which dose to use for medications that might treat a mental health condition.. To date,
the medical studies on genetic testing for mental health or for managing drug dosing do not
show that information from the test will change treatment or lead to better outcomes.
Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a
service may be covered.
Policy Coverage Criteria
https://www.premera.com/medicalpolicies/12.04.131.pdf
Page | 2 of 15
Testing Investigational Genetic testing for mental
health conditions
Genetic testing for variants associated with mental health
disorders is considered investigational in all situations,
including but not limited to the following:
To confirm a diagnosis of a mental health disorder in an
affected individual.
To predict future risk of a mental health disorder in an
asymptomatic individual.
To choose a medication or decide on its dose in order to treat
mental health disorders in an affected individual.
Genetic panels for
selecting medications or
doses of medication
Genetic testing panels, including but not limited to the
following tests, are considered investigational for selecting
medications or doses of medications for the treatment of
psychiatric or mental health symptoms or disorders:
Ally Diagnostics Genetic Testing Panel
Alpha Genomics Psychiatry/ADHD Panel
Frontier PGx Pharmacogenomic Testing
Genecept Assay
GeneSight Psychotropic Panel
Genetic Technological Innovations Pharmacogenetic Testing
Luminex xTAG CYP2C19 assay
Luminex xTAG CYP2D6 assay
Mental Health Insight DNA
Millennium Pharmacogenetic Testing
Molecular Testing Labs Psychotropic Medication Panel
PersonaGene
PGXL Multi-Drug Panel
PharmaRisk Basic
PharmaRisk Psychiatric Panel
Physicians Choice Laboratory Services (PCLS) Pharmacogenetic
Testing
Primex Expanded Pharmacogenomics Panel
Progenity Informed PGx Pharmacogenetic Testing
Proove Drug Metabolism Panel
Proove Opioid Risk assay
STA2R SureGene
YouScript Panel
Page | 3 of 15
Coding
Code Description
CPT 0015U Drug metabolism (adverse drug reactions), DNA, 22 drug metabolism and transporter
genes, real-time PCR, blood or buccal swab, genotype and metabolizer status for
therapeutic decision support (code terminated 1/1/18)
81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19)(eg, drug
metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17)
81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6)(eg, drug metabolism),
gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41,
*1XN, *2XN, *4XN)
81291 MTHFR (5, 10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability)
gene analysis; common variants (eg, 677T, 1298C)
81328 SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse
drug reaction), gene analysis, common variant(s) (eg, *5) (new code effective 1/1/18)
81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism),
gene analysis, common variant(s) (eg, -1639G>A, c.173+1000C>T)
81401 CYP3A4 (cytochrome P450, family 3, subfamily A, polypeptide 4) (eg, drug
metabolism), common variants (eg, *2, *3, *4, *5, *6)
81479 Unlisted molecular pathology procedure
Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS
codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).
Related Information
Genes Relevant to Mental Health Disorders
Mental disorders encompass a wide range of conditions: the DSM-5 includes more than 300
different disorders. However, currently available genetic testing for mental health disorders is
primarily related to several clinical situations:
Page | 4 of 15
1. Risk stratifying patients for one of several mental health conditions, including schizophrenia
and related psychotic disorders, bipolar and related disorders, depressive disorders,
obsessive-compulsive and related disorders, and substance-related and addictive disorders.
2. Predicting patients response to, dose requirement for, or adverse effects from one of several
medications (or classes of medications) used to treat mental health conditions, including:
typical and atypical antipsychotic agents, serotonin and serotonin/norepinephrine reuptake
inhibitors (SSRIs), and medications used to treat addiction, such as disulfiram.
Panels of genetic tests have been developed and have been proposed for use in the
management of mental health disorders.
Commercially Available Genetic Tests
Several test labs market either panels of tests or individual tests designed as being relevant for
mental health disorders. The following list includes many examples, but not necessarily all, of the
available tests.
The Genecept Assay (Genomind, LLC, Chalfont, PA) is a genetic panel test that includes a
range of genetic mutations and/or polymorphisms that have been associated with psychiatric
disorders and/or response to psychotropic medication. The test consists of a group of individual
genes, and the results are reported separately for each gene. There is no summary score or
aggregate results derived from this test. The intent of the test is as a decision aid for treatment
interventions, particularly in the choice and dosing of medications. However, guidance on
specific actions that should be taken following specific results of the test is vague. Interpretation
of the results and any management changes as a result of the test are left to the judgment of
the treating clinician.
The STA2R (SureGene Test for Antipsychotic and Antidepressant Response, SureGene, LLC,
Louisville, KY) is another genetic panel that provides information about medication response,
adverse event likelihood, and drug metabolism. According to the manufacturers website, the
test is recommended for initial medication selection, for patients who have poor efficacy,
tolerability, or satisfaction with existing medications, and in cases of severe treatment failure.1
Specific mutations included in the panel were not easily identified from the manufacturers
website.
GeneSight Psychotropic (Assurex Health, Mason, OH) is a genetic panel that provides
information about genes that may affect a patients response to antidepressant and
antipsychotic pharmacotherapy. According to the manufacturers website, following testing the
treating provider receives a report with the most common medications for the patients
Page | 5 of 15
diagnosed condition categorized by cautionary level, along with a report of the patients genetic
variants.2 Details are not provided about the algorithm used by the manufacturer to generate
risk levels.
The Proove Opioid Risk Panel (Proove Biosciences, Irvine, CA) is a panel to evaluate genes
involved in the development of substance abuse or dependence and in response to medical
therapy for substance abuse or dependence.
Pathway Genomics (San Diego, CA) offers the Mental Health DNA Insight panel, which is a
single nucleotide polymorphism-based array test which evaluates a number of genes associated
with the metabolism and efficacy of psychiatric medications.
AltheaDx (San Diego, CA) offers a number of IDgenetix-branded tests, which include several
panels focusing on polymorphisms that affect medication pharmacokinetics for a variety of
disorders, including psychiatric disorders. Specific mutations included in the panel were not
easily identified from the manufacturers website.
The Ally Diagnostics Genetic Testing Panel (Ally Clinical Diagnostics, Farmers Branch, Texas) is
a panel to evaluate genes that may affect a patients response to medications for the treatment
of psychiatric or mental health symptoms or disorders. The panel includes three CYP450 tests,
vitamin K epoxide reductase, and a non-specific molecular pathology procedure.
Molecular Testing Labs Psychotropic Medication Panel (Molecular Testing Labs, Vancouver,
WA) offers a genetic testing panel which their website describes as identifying five different
categories of patients by the way they metabolize specific drugs. The only specific gene
mentioned is CYP2D6.
The PharmaRisk Basic Panel Is described by OptimumMeds as a test that analyzes the genes
that metabolize many commonly prescribed medications used in all clinical practices including:
internal medicine, cardiology, geriatrics, psychiatry and chronic pain management. The test
analyzes 55 genetic markers across 4 genes CYP2C19, CYP2C9, CYP2D6 and VKORC1.
The PharmaRisk Psychiatric Panel Includes CYP2D6, OPRM1, CYP2C9, COMT, DRD2, CYP2B6,
CYP2C19, CYP1A2, UGT2B15.
The PGXL Multi-Drug Panel Includes CYP2D6, CYP2C9, CYP2C190, CYP1A2, CYP3A4, CYP3A5,
SLC6A4, OPRM1, VKORC1, SLCO1B1, SULT24A1, Factor II, Factor V, MTHFR and COM.
The Alpha Genomix Psychiatry/ADHD Panel Includes CYP1A2, CYP2C9, CYP2C19, CYP2D6,
CYP3A, ADRA2A, and COMT.
Genetic Technological Innovations (DBA Vantari Genetics) offers genetic testing for drug
metabolism, preconception and pregnancy, inherited conditions and inherited cancer. Their
pharmacogenetic panel for drug metabolism includes CYP2C19, CYP2D6, MTHFR and CYP3A4.
Page | 6 of 15
The PersonaGene panel Uses next generation sequencing to test for metabolism of common
drugs for pain management, cardiology, psychiatry and urology. Although this large panel
encompassing four specialties, all of the mutations tested are within the CYP450 family.
Luminex Offers a genotyping assay which can aid clinicians in determining therapeutic strategy
for drugs metabolized by cytochrome P450.
There are three Progenity Informed PGx genetic testing panels ADHD (4 mutations),
Depression (7 mutations) and Psychotropic (7 mutations) - and each panel tests a variety of
CYP450 genes, MTHFR, etc. In addition to the available panel tests, several labs offer genetic
testing for individual genes, including MTFHR, CYP450 genes, and SULT4A1.
Evidence Review
Description
Several commercially available testing panels include genes related to neurotransmitter function
and pharmacokinetics of psychiatric drugs. They are intended to be an aid in clinical decision
making regarding interventions for psychiatric conditions.
Background
Psychiatric disorders cover a wide range of clinical phenotypes and are generally classified by
symptomatology in systems such as the classification outlined in the American Psychiatric
Associations Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In
addition to counseling and other forms of behavioral treatment, treatment commonly involves
one or more psychotropic medications that are aimed at alleviating symptoms of the disorder.
Although there are a wide variety of effective medications, treatment of psychiatric disease is
characterized by relatively high rates of inadequate response. This often necessitates numerous
trials of individual agents and combinations of medications in order to achieve optimal
response.
Knowledge of the physiologic and genetic underpinnings of psychiatric disorders is advancing
rapidly and may substantially alter the way in which these disorders are classified and treated.
Genetic testing could potentially be used in several ways including stratifying patients risks of
developing a particular disorder, aiding diagnosis, targeting medication therapy, and optimally
Page | 7 of 15
dosing medication. Better understanding of these factors may lead to an improved ability to
target medications to the specific underlying abnormalities, with potential improvement in the
efficiency and efficacy of treatment.
Summary of Evidence
Panels of multiple genetic tests have been developed to aid in the diagnosis and treatment of
mental health disorders. Genes included in the panels have shown some association with
psychiatric disorders or with the pharmacokinetics of psychotropic medications.
Evidence on the clinical validity of genetic testing for mental health disorders consists primarily
of genome-wide association studies (GWAS) that correlate specific genetic polymorphisms with
clinical factors, and case-control studies that examine the odds ratio for genetic variants in
individuals with a clinical disorder compared with individuals without the disorder. In general,
cross-sectional and case-control studies cannot be used to generate diagnostic characteristics
such as sensitivity and specificity or clinically relevant risk prediction.
Studies suggest that there may be a number of genetic variants associated with increased risk of
mental health disorders and/or response to specific treatment, although estimates of the
magnitude of the increased risk and findings of significance are variable across studies. For the
individual tests, results from GWAS and case control studies are insufficient to determine clinical
utility. To determine clinical utility, evidence is needed that testing for variants in these genes
leads to changes in clinical management that improve outcomes.
No clinically valid studies were identified that evaluated defined groups of patients (eg, patients
with schizophrenia) and reported the sensitivity and specificity of the panel results for those
patients. Therefore it is not possible to estimate the clinical sensitivity and specificity of the tests
as a diagnostic tool for specific patient groups.
Practice Guidelines and Position Statements
None identified.
Page | 8 of 15
Regulatory Status
The Genecept Assay, STA2R test, the GeneSight Psychotropic panel and the GeneSight MTFHR
tests are laboratory-developed tests that are not subject to U.S. Food and Drug Administration
(FDA) approval. Clinical laboratories may develop and validate tests in-house (home-brew) and
market them as a laboratory service; such tests must meet the general regulatory standards of
the Clinical Laboratory Improvement Act (CLIA). Other examples of these tests are YouScript
(Genelex), Proove Drug Metabolism (PROOVEBio), Mental Health Insight DNA (Pathway
Genomics), Millennium Pharmacogenetic Testing (Millennium Health), Primex Expanded
Pharmacogenomics Panel (PrimexLab) and DNA Test Assay Pain Management Panel (Ally Clinical
Diagnostics).
Tests include three CYP450 tests, vitamin K epoxide reductase, and a non-specific molecular
pathology procedure.
References
1. SureGene L. STA2R -- Overview. 2012; https://www.suregenetest.com/ Accessed July 2017.
2. Assurex. GeneSight Informative Letter. http://assurexhealth.com Accessed July 2017.
3. Gatt JM, Burton KL, Williams LM, et al. Specific and common genes implicated across major mental disorders: a review of meta-
analysis studies. J Psychiatr Res. Jan 2015;60:1-13. PMID 25287955
4. Hariri AR, Mattay VS, Tessitore A, et al. Serotonin transporter genetic variation and the response of the human amygdala.
Science. Jul 19 2002;297(5580):400-403. PMID 12130784
5. Lasky-Su JA, Faraone SV, Glatt SJ, et al. Meta-analysis of the association between two polymorphisms in the serotonin
transporter gene and affective disorders. Am J Med Genet B Neuropsychiatr Genet. Feb 5 2005;133B(1):110-115. PMID
15578606
6. Enoch MA, Gorodetsky E, Hodgkinson C, et al. Functional genetic variants that increase synaptic serotonin and 5-HT3 receptor
sensitivity predict alcohol and drug dependence. Mol Psychiatry. Nov 2011;16(11):1139-1146.PMID 20838391
7. Sen S, Burmeister M, Ghosh D. Meta-analysis of the association between a serotonin transporter promoter polymorphism (5-
HTTLPR) and anxiety-related personality traits. Am J Med Genet B Neuropsychiatr Genet. May15 2004;127B(1):85-89. PMID
15108187
8. Minelli A, Bonvicini C, Scassellati C, et al. The influence of psychiatric screening in healthy populations selection: a new study
and meta-analysis of functional 5-HTTLPR and rs25531 polymorphisms and anxiety-related personality traits. BMC Psychiatry.
2011;11:50. PMID 21453464
9. Risch N, Herrell R, Lehner T, et al. Interaction between the serotonin transporter gene (5-HTTLPR), stressful life events, and risk
of depression: a meta-analysis. JAMA. Jun 17 2009;301(23):2462-2471. PMID 19531786
10. Karg K, Burmeister M, Shedden K, et al. The serotonin transporter promoter variant (5-HTTLPR), stress, and depression meta-
analysis revisited: evidence of genetic moderation. Arch Gen Psychiatry. May 2011;68(5):444- 454. PMID 21199959
https://www.suregenetest.com/http://assurexhealth.com/
Page | 9 of 15
11. Kiyohara C, Yoshimasu K. Association between major depressive disorder and a functional polymorphism of the 5-
hydroxytryptamine (serotonin) transporter gene: a meta-analysis. Psychiatr Genet. Apr 2010;20(2):49-58. PMID 20016401
12. Meltzer HY, Brennan MD, Woodward ND, et al. Association of Sult4A1 SNPs with psychopathology and cognition in patients
with schizophrenia or schizoaffective disorder. Schizophr Res. Dec 2008;106(2-3):258-264. PMID 18823757
13. Craddock N, Sklar P. Genetics of bipolar disorder. Lancet. May 11 2013;381(9878):1654-1662. PMID 23663951
14. Jiang H, Qiao F, Li Z, et al. Evaluating the association between CACNA1C rs1006737 and schizophrenia risk: A meta-analysis.
Asia Pac Psychiatry. Jan 15 2015. PMID 25588813
15. Kloiber S, Czamara D, Karbalai N, et al. ANK3 and CACNA1C--missing genetic link for bipolar disorder and major depressive
disorder in two German case-control samples. J Psychiatr Res. Aug 2012;46(8):973-979. PMID 22647524
16. Bruder GE, Keilp JG, Xu H, et al. Catechol-O-methyltransferase (COMT) genotypes and working memory: associations with
differing cognitive operations. Biol Psychiatry. Dec 1 2005;58(11):901-907. PMID 16043133
17. Lelli-Chiesa G, Kempton MJ, Jogia J, et al. The impact of the Val158Met catechol-O-methyltransferase genotype on neural
correlates of sad facial affect processing in patients with bipolar disorder and their relatives. Psychol Med. Apr 2011;41(4):779-
788. PMID 20667170
18. Barnett JH, Scoriels L, Munafo MR. Meta-analysis of the cognitive effects of the catechol-O-methyltransferase gene
Val158/108Met polymorphism. Biol Psychiatry. Jul 15 2008;64(2):137-144. PMID 18339359
19. Zammit S, Spurlock G, Williams H, et al. Genotype effects of CHRNA7, CNR1 and COMT in schizophrenia: interactions with
tobacco and cannabis use. Br J Psychiatry. Nov 2007;191:402-407. PMID 17978319
20. Jonsson EG, Sillen A, Vares M, et al. Dopamine D2 receptor gene Ser311Cys variant and schizophrenia: association study and
meta-analysis. Am J Med Genet B Neuropsychiatr Genet. May 15 2003;119B(1):28-34. PMID 12707934
21. Liu L, Fan D, Ding N, et al. The relationship between DRD2 gene polymorphisms (C957T and C939T) and schizophrenia: a meta-
analysis. Neurosci Lett. Nov 7 2014;583:43-48. PMID 25240594
22. Zou YF, Wang F, Feng XL, et al. Association of DRD2 gene polymorphisms with mood disorders: a metaanalysis. J Affect Disord.
Feb 2012;136(3):229-237. PMID 21130502
23. Lopez Leon S, Croes EA, Sayed-Tabatabaei FA, et al. The dopamine D4 receptor gene 48-base-pair-repeat polymorphism and
mood disorders: a meta-analysis. Biol Psychiatry. May 1 2005;57(9):999-1003. PMID 15860340
24. Zhu F, Yan CX, Wang Q, et al. An association study between dopamine D1 receptor gene polymorphisms and the risk of
schizophrenia. Brain Res. Oct 28 2011;1420:106-113. PMID 21955727
25. Batel P, Houchi H, Daoust M, et al. A haplotype of the DRD1 gene is associated with alcohol dependence. Alcohol Clin Exp Res.
Apr 2008;32(4):567-572. PMID 18341651
26. Huang W, Ma JZ, Payne TJ, et al. Significant association of DRD1 with nicotine dependence. Hum Genet. Mar 2008;123(2):133-
140. PMID 18092181
27. Pan Y, Yao J, Wang B. Association of dopamine D1 receptor gene polymorphism with schizophrenia: a metaanalysis.
Neuropsychiatr Dis Treat. 2014;10:1133-1139. PMID 25018632
28. Stapleton JA, Sutherland G, O'Gara C. Association between dopamine transporter genotypes and smoking cessation: a meta-
analysis. Addict Biol. Jun 2007;12(2):221-226. PMID 17508996
29. Du Y, Nie Y, Li Y, et al. The association between the SLC6A3 VNTR 9-repeat allele and alcoholism-a metaanalysis. Alcohol Clin
Exp Res. Sep 2011;35(9):1625-1634. PMID 21554332
30. Xu M, Lin Z. Genetic influences of dopamine transport gene on alcohol dependence: a pooled analysis of 13 studies with 2483
cases and 1753 controls. Prog Neuropsychopharmacol Biol Psychiatry. Jul 1 2011;35(5):1255- 1260. PMID 21078357
31. Wu YL, Ding XX, Sun YH, et al. Association between MTHFR C677T polymorphism and depression: An updated meta-analysis of
26 studies. Prog Neuropsychopharmacol Biol Psychiatry. Oct 1 2013;46:78-85. PMID 23831680
Page | 10 of 15
32. Hu CY, Qian ZZ, Gong FF, et al. Methylenetetrahydrofolate reductase (MTHFR) polymorphism susceptibility to schizophrenia
and bipolar disorder: an updated meta-analysis. J Neural Transm. Feb 2015;122(2):307-320. PMID 24938371
33. Bousman CA, Potiriadis M, Everall IP, et al. Methylenetetrahydrofolate reductase (MTHFR) genetic variation and major
depressive disorder prognosis: A five-year prospective cohort study of primary care attendees. Am J Med Genet B
Neuropsychiatr Genet. Jan 2014;165(1):68-76. PMID 24123968
34. Lizer MH, Bogdan RL, Kidd RS. Comparison of the frequency of the methylenetetrahydrofolate reductase (MTHFR) C677T
polymorphism in depressed versus nondepressed patients. J Psychiatr Pract. Nov 2011;17(6):404-409. PMID 22108397
35. Peerbooms OL, van Os J, Drukker M, et al. Meta-analysis of MTHFR gene variants in schizophrenia, bipolar disorder and
unipolar depressive disorder: evidence for a common genetic vulnerability? Brain Behav Immun. Nov 2011;25(8):1530-1543.
PMID 21185933
36. Altar CA, Hornberger J, Shewade A, et al. Clinical validity of cytochrome P450 metabolism and serotonin gene variants in
psychiatric pharmacotherapy. Int Rev Psychiatry. Oct 2013;25(5):509-533. PMID 24151799
37. Yin L, Zhang YY, Zhang X, et al. TPH, SLC6A2, SLC6A3, DRD2 and DRD4 Polymorphisms and Neuroendocrine Factors Predict
SSRIs Treatment Outcome in the Chinese Population with Major Depression. Pharmacopsychiatry. Feb 2 2015. PMID 25642918
38. Matsumoto Y, Fabbri C, Pellegrini S, et al. Serotonin transporter gene: a new polymorphism may affect response to
antidepressant treatments in major depressive disorder. Mol Diagn Ther. Oct 2014;18(5):567-577. PMID 24958631
39. Zhang JP, Lencz T, Malhotra AK. D2 receptor genetic variation and clinical response to antipsychotic drug treatment: a meta-
analysis. Am J Psychiatry. Jul 2010;167(7):763-772. PMID 20194480
40. Hwang R, Shinkai T, De Luca V, et al. Association study of four dopamine D1 receptor gene polymorphisms and clozapine
treatment response. J Psychopharmacol. Sep 2007;21(7):718-727. PMID 17092969
41. Porcelli S, Fabbri C, Serretti A. Meta-analysis of serotonin transporter gene promoter polymorphism (5-HTTLPR) association with
antidepressant efficacy. Eur Neuropsychopharmacol. Apr 2012;22(4):239-258. PMID 22137564
42. Lenze EJ, Goate AM, Nowotny P, et al. Relation of serotonin transporter genetic variation to efficacy of escitalopram for
generalized anxiety disorder in older adults. J Clin Psychopharmacol. Dec 2010;30(6):672-677. PMID 21105279
43. Seripa D, Pilotto A, Paroni G, et al. Role of the serotonin transporter gene locus in the response to SSRI treatment of major
depressive disorder in late life. J Psychopharmacol. Mar 31 2015. PMID 25827644
44. Tomita T, Yasui-Furukori N, Nakagami T, et al. The influence of 5-HTTLPR genotype on the association between the plasma
concentration and therapeutic effect of paroxetine in patients with major depressive disorder. PLoS One. 2014;9(5):e98099.
PMID 24858363
45. Lewis G, Mulligan J, Wiles N, et al. Polymorphism of the 5-HT transporter and response to antidepressants: randomised
controlled trial. Br J Psychiatry. Jun 2011;198(6):464-471. PMID 21263010
46. Daray FM, Thommi SB, Ghaemi SN. The pharmacogenetics of antidepressant-induced mania: a systematic review and meta-
analysis. Bipolar Disord. Nov 2010;12(7):702-706. PMID 21040287
47. Biernacka JM, McElroy SL, Crow S, et al. Pharmacogenomics of antidepressant induced mania: a review and meta-analysis of the
serotonin transporter gene (5HTTLPR) association. J Affect Disord. Jan 2012;136(1-2):e21-29. PMID 21680025
48. Johnson BA, Ait-Daoud N, Seneviratne C, et al. Pharmacogenetic approach at the serotonin transporter gene as a method of
reducing the severity of alcohol drinking. Am J Psychiatry. Mar 2011;168(3):265-275. PMID 21247998
49. Chamorro AJ, Marcos M, Miron-Canelo JA, et al. Association of micro-opioid receptor (OPRM1) gene polymorphism with
response to naltrexone in alcohol dependence: a systematic review and meta-analysis. Addict Biol. May 2012;17(3):505-512.
PMID 22515274
50. Breitenstein B, Bruckl TM, Ising M, et al. ABCB1 gene variants and antidepressant treatment outcome: A metaanalysis. Am J Med
Genet B Neuropsychiatr Genet. Apr 2 2015. PMID 25847751
Page | 11 of 15
51. Matchar DB, Thakur ME, Grossman I, et al. Testing for cytochrome P450 polymorphisms in adults with non-psychotic depression
treated with selective serotonin reuptake inhibitors (SSRIs). Evid Rep Technol Assess (Full Rep). Jan 2007(146):1-77. PMID
17764209
52. Recommendations from the EGAPP Working Group: testing for cytochrome P450 polymorphisms in adults with nonpsychotic
depression treated with selective serotonin reuptake inhibitors. Genet Med. Dec 2007; 9(12):819-825. PMID 18091431
53. Gex-Fabry M, Eap CB, Oneda B, et al. CYP2D6 and ABCB1 genetic variability: influence on paroxetine plasma level and
therapeutic response. Ther Drug Monit. Aug 2008; 30(4):474-482. PMID 18641553
54. Ververs FF, Voorbij HA, Zwarts P, et al. Effect of cytochrome P450 2D6 genotype on maternal paroxetine plasma concentrations
during pregnancy. Clin Pharmacokinet. 2009; 48(10):677-683. PMID 19743889
55. Tsai MH, Lin KM, Hsiao MC, et al. Genetic polymorphisms of cytochrome P450 enzymes influence metabolism of the
antidepressant escitalopram and treatment response. Pharmacogenomics. Apr 2010; 11(4):537-546. PMID 20350136
56. Hodgson K, Tansey K, Dernovsek MZ, et al. Genetic differences in cytochrome P450 enzymes and antidepressant treatment
response. J Psychopharmacol. Feb 2014; 28(2):133-141. PMID 24257813
57. Chang M, Tybring G, Dahl ML, et al. Impact of Cytochrome P450 2C19 Polymorphisms on Citalopram/Escitalopram Exposure: A
Systematic Review and Meta-Analysis. Clin Pharmacokinet. Sep 2014; 53(9):801-811. PMID 25154506
58. Serretti A, Calati R, Massat I, et al. Cytochrome P450 CYP1A2, CYP2C9, CYP2C19 and CYP2D6 genes are not associated with
response and remission in a sample of depressive patients. Int Clin Psychopharmacol. Sep 2009; 24(5):250-256. PMID 19593158
59. Sim SC, Nordin L, Andersson TM, et al. Association between CYP2C19 polymorphism and depressive symptoms. Am J Med
Genet B Neuropsychiatr Genet. Sep 2010; 153B (6):1160-1166. PMID 20468063
60. Bertilsson L. Metabolism of antidepressant and neuroleptic drugs by cytochrome p450s: clinical and interethnic aspects. Clin
Pharmacol Ther. Nov 2007; 82(5):606-609. PMID 17898711
61. Lobello KW, Preskorn SH, Guico-Pabia CJ, et al. Cytochrome P450 2D6 phenotype predicts antidepressant efficacy of
venlafaxine: a secondary analysis of 4 studies in major depressive disorder. J Clin Psychiatry. Nov 2010; 71(11):1482-1487. PMID
20441720
62. Waade RB, Hermann M, Moe HL, et al. Impact of age on serum concentrations of venlafaxine and escitalopram in different
CYP2D6 and CYP2C19 genotype subgroups. Eur J Clin Pharmacol. Aug 2014; 70(8):933-940. PMID 24858822
63. Skinner MH, Kuan HY, Pan A, et al. Duloxetine is both an inhibitor and a substrate of cytochrome P4502D6 in healthy
volunteers. Clin Pharmacol Ther. Mar 2003; 73(3):170-177. PMID 12621382
64. de Leon J. The crucial role of the therapeutic window in understanding the clinical relevance of the poor versus the ultrarapid
metabolizer phenotypes in subjects taking drugs metabolized by CYP2D6 or CYP2C19. J Clin Psychopharmacol. Jun
2007;27(3):241-245. PMID 17502769
65. Trzepacz PT, Williams DW, Feldman PD, et al. CYP2D6 metabolizer status and atomoxetine dosing in children and adolescents
with ADHD. Eur Neuropsychopharmacol. Feb 2008; 18(2):79-86. PMID 17698328
66. Michelson D, Read HA, Ruff DD, et al. CYP2D6 and clinical response to atomoxetine in children and adolescents with ADHD. J
Am Acad Child Adolesc Psychiatry. Feb 2007; 46(2):242-251. PMID 17242628
67. Wernicke JF, Kratochvil CJ. Safety profile of atomoxetine in the treatment of children and adolescents with ADHD. J Clin
Psychiatry. 2002; 63 Suppl 12:50-55. PMID 12562062
68. http://www.ehs.lilly.com/msds/msds_atomoxetine_hydrochloride_tablets_and_capsules.pdf Accessed July 2017.
69. Ramoz N, Boni C, Downing AM, et al. A haplotype of the norepinephrine transporter (Net) gene Slc6a2 is associated with clinical
response to atomoxetine in attention-deficit hyperactivity disorder (ADHD). Neuropsychopharmacology. Aug 2009; 34(9):2135-
2142. PMID 19387424
70. ter Laak MA, Temmink AH, Koeken A, et al. Recognition of impaired atomoxetine metabolism because of low CYP2D6 activity.
Pediatr Neurol. Sep 2010; 43(3):159-162. PMID 20691935
http://www.ehs.lilly.com/msds/msds_atomoxetine_hydrochloride_tablets_and_capsules.pdf
Page | 12 of 15
71. Macaluso M, Preskorn SH. CYP 2D6 PM status and antidepressant response to nortriptyline and venlafaxine: is it more than just
drug metabolism? J Clin Psychopharmacol. Apr 2011; 31(2):143-145. PMID 21346604
72. de Vos A, van der Weide J, Loovers HM. Association between CYP2C19*17 and metabolism of amitriptyline, citalopram and
clomipramine in Dutch hospitalized patients. Pharmacogenomics J. Oct 2011; 11(5):359-367. PMID 20531370
73. Hodgson K, Tansey K, Dernovsek MZ et al. Genetic differences in cytochrome P450 enzymes and antidepressant treatment
response. J Psychopharmacol. Feb 2014;28(2):133-141. PMID 24257813
74. Jornil J, Jensen KG, Larsen F, et al. Risk assessment of accidental nortriptyline poisoning: the importance of cytochrome P450 for
nortriptyline elimination investigated using a population-based pharmacokinetic simulator. Eur J Pharm Sci. Oct 9 2011;
44(3):265-272. PMID 21854846
75. Maier W, Zobel A. Contribution of allelic variations to the phenotype of response to antidepressants and antipsychotics. Eur
Arch Psychiatry Clin Neurosci. Mar 2008; 258 Suppl 1:12-20. PMID 18344045
76. Crescenti A, Mas S, Gasso P, et al. Cyp2d6*3, *4, *5 and *6 polymorphisms and antipsychotic induced extrapyramidal side-
effects in patients receiving antipsychotic therapy. Clin Exp Pharmacol Physiol. Jul 2008; 35(7):807-811. PMID 18346175
77. Smoller JW. Incorporating pharmacogenetics into clinical practice: reality of a new tool in psychiatry. Practical issues related to
medication selection. CNS Spectr. Mar 2006; 11(3 Suppl 3):5-7. PMID 17760223
78. Panagiotidis G, Arthur HW, Lindh JD, et al. Depot haloperidol treatment in outpatients with schizophrenia on monotherapy:
impact of CYP2D6 polymorphism on pharmacokinetics and treatment outcome. Ther Drug Monit. Aug 2007; 29(4):417-422.
PMID 17667795
79. Murray M, Petrovic N. Cytochromes P450: decision-making tools for personalized therapeutics. Curr Opin Mol Ther. Dec 2006;
8(6):480-486. PMID 17243482
80. Murray M. Role of CYP pharmacogenetics and drug-drug interactions in the efficacy and safety of atypical and other
antipsychotic agents. J Pharm Pharmacol. Jul 2006; 58(7):871-885. PMID 16805946
81. Bondy B, Spellmann I. Pharmacogenetics of antipsychotics: useful for the clinician? Curr Opin Psychiatry. Mar 2007; 20(2):126-
130. PMID 17278909
82. Vandel P, Talon JM, Haffen E, et al. Pharmacogenetics and drug therapy in psychiatry--the role of the CYP2D6 polymorphism.
Curr Pharm Des. 2007; 13(2):241-250. PMID 17269931
83. Dorado P, Berecz R, Penas-Lledo EM, et al. Clinical implications of CYP2D6 genetic polymorphism during treatment with
antipsychotic drugs. Curr Drug Targets. Dec 2006; 7(12):1671-1680. PMID 17168842
84. Fleeman N, McLeod C, Bagust A, et al. The clinical effectiveness and cost-effectiveness of testing for cytochrome P450
polymorphisms in patients with schizophrenia treated with antipsychotics: a systematic review and economic evaluation. Health
Technol Assess. Jan 2010; 14(3):1-157, iii. PMID 20031087
85. Fleeman N, Dundar Y, Dickson R, et al. Cytochrome P450 testing for prescribing antipsychotics in adults with schizophrenia:
systematic review and meta-analyses. Pharmacogenomics J. Feb 2011; 11(1):1-14. PMID 20877299
86. Jovanovic N, Bozina N, Lovric M, et al. The role of CYP2D6 and ABCB1 pharmacogenetics in drug-naive patients with first-
episode schizophrenia treated with risperidone. Eur J Clin Pharmacol. Nov 2010; 66(11):1109-1117. PMID 20563569
87. Locatelli I, Kastelic M, Koprivsek J, et al. A population pharmacokinetic evaluation of the influence of CYP2D6 genotype on
risperidone metabolism in patients with acute episode of schizophrenia. Eur J Pharm Sci. Oct 9 2010; 41(2):289-298. PMID
20599499
88. Almoguera B, Riveiro-Alvarez R, Lopez-Castroman J, et al. CYP2D6 poor metabolizer status might be associated with better
response to risperidone treatment. Pharmacogenet Genomics. Nov 2013; 23(11):627-630. PMID 24026091
89. Madadi P, Ross CJ, Hayden MR, et al. Pharmacogenetics of neonatal opioid toxicity following maternal use of codeine during
breastfeeding: a case-control study. Clin Pharmacol Ther. Jan 2009; 85(1):31-35. PMID 18719619
Page | 13 of 15
90. Koren G, Cairns J, Chitayat D, et al. Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine-prescribed
mother. Lancet. Aug 19 2006; 368(9536):704. PMID 16920476
91. U.S. Food and Drug Administration. Information for Healthcare Professionals: Use of Codeine Products in Nursing Mothers.
Available online at
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124889.htm
Accessed July 2017.
92. Madadi P, Ciszkowski C, Gaedigk A, et al. Genetic transmission of cytochrome P450 2D6 (CYP2D6) ultrarapid metabolism:
implications for breastfeeding women taking codeine. Curr Drug Saf. Feb 1 2011; 6(1):36-39. PMID 21241245
93. Hall-Flavin DK, Winner JG, Allen JD, et al. Utility of integrated pharmacogenomic testing to support the treatment of major
depressive disorder in a psychiatric outpatient setting. Pharmacogenet Genomics. Oct 2013;23(10):535- 548. PMID 24018772
94. Hall-Flavin DK, Winner JG, Allen JD, et al. Using a pharmacogenomic algorithm to guide the treatment of depression. Transl
Psychiatry. 2012;2:e172.
95. Winner JG, Carhart JM, Altar CA, et al. A prospective, randomized, double-blind study assessing the clinical impact of integrated
pharmacogenomic testing for major depressive disorder. Discov Med. Nov 2013;16(89):219- 227. PMID 24229738
96. Altar CA, Carhart JM, Allen JD, et al. Clinical validity: Combinatorial pharmacogenomics predicts antidepressant responses and
healthcare utilizations better than single gene phenotypes. Pharmacogenomics J. Feb 17 2015. PMID 25686762
97. Genomind (Chalfont, PA) website. http://genomind.com/ Accessed July 2017.
98. Breitenstein B, Scheuer S, Pfister H, et al. The clinical application of ABCB1 genotyping in antidepressant treatment: a pilot
study. CNS Spectr. Apr 2014;19(2):165-175. PMID 23880209
History
Date Comments 12/09/13 New Policy. New policy developed with literature review through September 30, 2013.
The Genecept assay is investigational for all indications.
05/23/14 Update Related Policies. Add 12.04.509 and removed 12.04.82 as it was deleted.
08/11/14 Annual Review. Policy updated with literature review through April 14, 2014. Policy
expanded to include other genetic testing panels for mental health disorders; title of
policy changed to Genetic Testing Panels for Mental Health Conditions. Rationale
extensively revised. References 1, 2, 7-11, 19-26, 28-8 added. Policy statement
changed to indicate that individual genetic tests (as mutations or genetic variations)
and genetic testing panels for mental health disorders are investigational.
09/10/14 Minor update. New test added to Policy Statement for genetic testing panels: Primex
Expanded Pharmacogenomics Panel.
12/17/14 Minor update. New tests added to investigational Policy Statement for genetic testing
panels: Ally Diagnostics Genetic Testing Panel and Molecular Testing Labs
Psychotropic Medication Panel. Section reformatted for ease of reading.
01/20/15 Minor update. New tests added to investigational Policy Statement for genetic testing
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124889.htmhttp://genomind.com/
Page | 14 of 15
Date Comments panels: PharmaRisk Basic and PharmaRisk Psychiatric Panel.
02/27/15 Minor update. New test added to investigational Policy Statement for genetic testing
panels: Physicians Choice Laboratory Services (PCLS) Pharmacogenetic Testing. Related
policies updated with new policy 12.04.131.
03/24/15 Minor update. New test added to investigational Policy statement for genetic testing
panels: Frontier Toxicology PGx Pharmacogenomic Testing.
04/24/15 Minor update: Alpha Genomix Psychiatry/ADHD Panel and PGXL Multi-Drug Panel
added to investigational Policy statement for genetic testing panels.
07/14/15 Annual Review. Policy number changed from 12.04.110 to 12.04.515 due to the
addition of several local plan tests to the Policy Statement, Description and Reference
section. In this revision, PersonaGene, Progenity PGx Informed and two Luminex panel
tests added. Policy updated with literature review through April 21, 2015. Numerous
references added. Policy statements changed to clarify which categories of genetic
testing the policy addresses; intent of policy statements unchanged.
10/19/15 Update Related Policies. Remove 12.04.509 as it was archived.
05/01/16 Annual Review, approved April 12, 2016. Added rationale and references for CYP450
for use in review of mental health conditions/medications. References 51-93 added.
No change in policy statements.
10/07/16 Coding update. Reference codes removed from Description section; these were
informational only. CPT codes 81355 and 81479 added to the Coding section.
02/14/17 Policy moved into new format; no change to policy statements. References missing in
error adding to Reference section.
08/01/17 Annual Review. Policy approved on July 25, 2017. No changes to policy statement.
10/01/17 Coding update. Added new CPT code 0015U (effective 8/1/17).
01/23/18 Coding update. Added new CPT code 81328 (new code effective 1/1/18).
01/30/18 Coding update, added note that CPT code 0015U was terminated 1/1/18.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The
Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and
local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review
and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit
booklet or contact a member service representative to determine coverage for a specific medical service or supply.
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). 2018 Premera
All Rights Reserved.
Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when
determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to
the limits and conditions of the member benefit plan. Members and their providers should consult the member
Page | 15 of 15
benefit booklet or contact a customer service representative to determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
037338 (07-2016)
Discrimination is Against the Law Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Premera: Provides free aids and services to people with disabilities to communicate
effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible
electronic formats, other formats) Provides free language services to people whose primary language is not
English, such as: Qualified interpreters Information written in other languages
If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator - Complaints and Appeals PO Box 91102, Seattle, WA 98111 Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357 Email [email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Getting Help in Other Languages This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 800-722-1471 (TTY: 800-842-5357). (Amharic): Premera Blue Cross 800-722-1471 (TTY: 800-842-5357)
:(Arabic) .
Premera Blue Cross. . . . (TTY: 800-842-5357) 1471-722-800
(Chinese): Premera Blue Cross
800-722-1471 (TTY: 800-842-5357)
Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu dandaa. Guyyaawwan murteessaa taan beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu dandaa. Kaffaltii irraa bilisa haala taeen afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa. Franais (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermdiaire de Premera Blue Cross. Le prsent avis peut contenir des dates cls. Vous devrez peut-tre prendre des mesures par certains dlais pour maintenir votre couverture de sant ou d'aide avec les cots. Vous avez le droit d'obtenir cette information et de laide dans votre langue aucun cot. Appelez le 800-722-1471 (TTY: 800-842-5357). Kreyl ayisyen (Creole): Avi sila a gen Enfmasyon Enptan ladann. Avi sila a kapab genyen enfmasyon enptan konsnan aplikasyon w lan oswa konsnan kouvti asirans lan atrav Premera Blue Cross. Kapab genyen dat ki enptan nan avi sila a. Ou ka gen pou pran kk aksyon avan sten dat limit pou ka kenbe kouvti asirans sante w la oswa pou yo ka ede w avk depans yo. Se dwa w pou resevwa enfmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan 800-722-1471 (TTY: 800-842-5357). Deutsche (German): Diese Benachrichtigung enthlt wichtige Informationen. Diese Benachrichtigung enthlt unter Umstnden wichtige Informationen bezglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie knnten bis zu bestimmten Stichtagen handeln mssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY: 800-842-5357). Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357). Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357). Italiano (Italian): Questo avviso contiene informazioni importanti. Questo avviso pu contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).
(Japanese): Premera Blue Cross
800-722-1471 (TTY: 800-842-5357) (Korean): . Premera Blue Cross . . . . 800-722-1471 (TTY: 800-842-5357) . (Lao): . Premera Blue Cross. . . . 800-722-1471 (TTY: 800-842-5357). (Khmer):
Premera Blue Cross
800-722-1471 (TTY: 800-842-5357) (Punjabi): . Premera Blue Cross . . , , 800-722-1471 (TTY: 800-842-5357).
:(Farsi) .
. Premera Blue Cross .
. .
)800-842-5357 TTY( 800-722-1471 .
Polskie (Polish): To ogoszenie moe zawiera wane informacje. To ogoszenie moe zawiera wane informacje odnonie Pastwa wniosku lub zakresu wiadcze poprzez Premera Blue Cross. Prosimy zwrcic uwag na kluczowe daty, ktre mog by zawarte w tym ogoszeniu aby nie przekroczy terminw w przypadku utrzymania polisy ubezpieczeniowej lub pomocy zwizanej z kosztami. Macie Pastwo prawo do bezpatnej informacji we wasnym jzyku. Zadzwocie pod 800-722-1471 (TTY: 800-842-5357). Portugus (Portuguese): Este aviso contm informaes importantes. Este aviso poder conter informaes importantes a respeito de sua aplicao ou cobertura por meio do Premera Blue Cross. Podero existir datas importantes neste aviso. Talvez seja necessrio que voc tome providncias dentro de determinados prazos para manter sua cobertura de sade ou ajuda de custos. Voc tem o direito de obter esta informao e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).
Romn (Romanian): Prezenta notificare conine informaii importante. Aceast notificare poate conine informaii importante privind cererea sau acoperirea asigurrii dumneavoastre de sntate prin Premera Blue Cross. Pot exista date cheie n aceast notificare. Este posibil s fie nevoie s acionai pn la anumite termene limit pentru a v menine acoperirea asigurrii de sntate sau asistena privitoare la costuri. Avei dreptul de a obine gratuit aceste informaii i ajutor n limba dumneavoastr. Sunai la 800-722-1471 (TTY: 800-842-5357). P (Russian): . Premera Blue Cross. . , , . . 800-722-1471 (TTY: 800-842-5357). Faasamoa (Samoan): Atonu ua iai i lenei faasilasilaga ni faamatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei faasilasilaga o se fesoasoani e faamatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Faamolemole, ia e iloilo faalelei i aso faapitoa oloo iai i lenei faasilasilaga taua. Masalo o lea iai ni feau e tatau ona e faia ao lei aulia le aso ua taua i lenei faasilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo oloo e iai i ai. Oloo iai iate oe le aia tatau e maua atu i lenei faasilasilaga ma lenei famatalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). Espaol (Spanish): Este Aviso contiene informacin importante. Es posible que este aviso contenga informacin importante acerca de su solicitud o cobertura a travs de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura mdica o ayuda con los costos. Usted tiene derecho a recibir esta informacin y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357). (Thai): Premera Blue Cross 800-722-1471 (TTY: 800-842-5357) (Ukrainian): . Premera Blue Cross. , . , , . . 800-722-1471 (TTY: 800-842-5357). Ting Vit (Vietnamese): Thng bo ny cung cp thng tin quan trng. Thng bo ny c thng tin quan trng v n xin tham gia hoc hp ng bo him ca qu v qua chng trnh Premera Blue Cross. Xin xem ngy quan trng trong thng bo ny. Qu v c th phi thc hin theo thng bo ng trong thi hn duy tr bo him sc khe hoc c tr gip thm v chi ph. Qu v c quyn c bit thng tin ny v c tr gip bng ngn ng ca mnh min ph. Xin gi s 800-722-1471 (TTY: 800-842-5357).
Top Related