Will patients get a surprise bill?

We work to prevent that. We verify coverage before testing, and if a patient would owe anything, we contact them first and they decide whether to go ahead.

Does Medicare cover PGx testing?

Yes, when its criteria are met: a clinician is considering or using a specific drug with an actionable gene-drug interaction (CPIC level A/B or FDA labeling) and needs the result for that decision. It is not covered based on a diagnosis alone.

Who verifies coverage?

Our program team works with billers and each patient's insurance plan to verify eligibility and identify any patient cost before the test runs.

What does a patient do with an Explanation of Benefits?

Keep it for their records. An EOB shows what the plan paid and is not a bill.

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Billing & coverage

Q: Do you handle prior authorizations?

Yes. When a plan requires prior authorization, our team submits and follows up on it.

Clear costs up front. We verify coverage before any test runs, and if a patient would owe anything, they hear from us and approve it first.

MedicareWhen criteria are met

Medicaid & Medi-CalVaries by state

CommercialVaries by plan

Patient costConfirmed first

How billing works

Coverage first, testing second

Step 1
Verify
We work with billers and the patient's plan to check eligibility and benefits.
Step 2
Confirm any cost
If there's an out-of-pocket cost, we call the patient first.
Step 3
Patient approves
Nothing moves forward without the patient's OK.
Step 4
Test runs
The lab processes the sample and bills the insurer directly.
Step 5
Statement
The patient may get an Explanation of Benefits from their plan.

Who handles billing

We work with billers and insurers, so your team doesn't have to

Our program team works with billers and each patient's insurance plan to verify eligibility before a sample is tested.

What our team handles

Eligibility verification

Coverage and eligibility for PGx testing are checked with the patient's plan before the test runs.

Prior authorizations

When a plan requires prior authorization, our team submits and follows up on it.

Patient cost check

If a patient would have an out-of-pocket cost, we contact them and confirm they want to go ahead.

Physician coordination

We send the ordering physician the requisition and consent, and collect the signed requisition.

Claims to the insurer

The lab bills the patient's plan directly. Your organization doesn't submit the claim.

What we need to verify coverage

A copy of the patient's insurance card
Face sheet or demographic information
Current medication list
Signed informed consent
Requisition signed by the ordering physician, with ICD-10 codes
Pharmacies: the completed pharmacist recommendation form

Send documents by secure fax or email. Your program specialist will share the details when you enroll.

Coverage by payer

Who covers PGx testing

Payer	Coverage	What's typically required
Medicare	When criteria are met	MolDX policy (LCD L38294): a clinician is considering or using a specific drug with an actionable gene-drug interaction (CPIC level A/B or FDA labeling) and needs the result for dosing or selection. Not covered on diagnosis alone. A multi-gene panel is covered only when more than one gene on it is needed.
Medicaid & Medi-Cal	Varies by state	Coverage rules vary by state. We verify each patient before testing.
Commercial plans	Varies by plan	Many plans cover PGx when their criteria are met. When a plan requires prior authorization, our team handles it.

For patients

Your questions about cost

Will I get a bill?

Before testing, we tell you if you are expected to owe anything, and nothing proceeds without your approval.

I got a statement from my plan

An Explanation of Benefits (EOB) shows what your plan paid. It is not a bill. Keep it for your records.

Questions about a bill?

Call our billing team at (618) 224-4383 or email info@achievedx.com. Have your statement handy.

For providers

Document medical necessity

Clear documentation keeps claims moving. For Medicare (MolDX), record these in the chart and on the requisition. Testing isn't covered based on a diagnosis alone.

The specific drug being considered or currently used
That it has an actionable gene-drug interaction (CPIC level A/B or FDA labeling)
How the result will guide dosing or drug selection
That non-genetic factors were also considered

A send-out test: no validation costs and no new staff.

Common PGx CPT codes

For reference. The codes billed depend on the genes tested.

CPT	Gene or panel
81225	CYP2C19
81226	CYP2D6
81227	CYP2C9
81355	VKORC1
81328	SLCO1B1
81335	TPMT
81418	Drug metabolism panel

Billing & coverage

Coverage first, testing second

Verify

Confirm any cost

Patient approves

Test runs

Statement

We work with billers and insurers, so your team doesn't have to

Eligibility verification

Prior authorizations

Patient cost check

Physician coordination

Claims to the insurer

Who covers PGx testing

Your questions about cost

Will I get a bill?

I got a statement from my plan

Questions about a bill?

Document medical necessity

Common PGx CPT codes

Check coverage for your patients.

What kind of organization are you?

Which testing do you want to explore?

Where should we send your program plan?

Thank you. Your request is in.

Frequently asked

PGx testing in 60 seconds

The same prescription can work differently for different people.

Almost half of spontaneously reported ADRs may have identifiable causes, most likely genetic.

Pharmacogenomic (PGx) testing reads the genes that control how your body processes medications.

It starts with one quick cheek swab.

Our CLIA-certified lab analyzes your DNA.

A pharmacist-reviewed report shows which medications fit your genes.

Test once. Use the results for life.

Coverage is checked before any test runs.

One quick test. Lifelong medication guidance.