A. Evaluation of the Analysis to Require Coverage for Pharmacogenomic Testing. The Contractor shall utilize its health care actuaries’ knowledge and experience, proprietary databases, in-house data, carrier surveys, and other externally available data sources to complete this actuarial evaluation, which includes the following: 1. A social evaluation including: a) the extent to which the coverage and reimbursement requirement (or “the service”) is generally utilized by a significant portion of the population; b) the extent to which the insurance coverage is already generally available; c) the extent to which the lack of coverage results in individuals avoiding necessary health care treatments; d) the extent to which the lack of coverage results in unreasonable financial hardship; e) the level of public demand for the service; f) the level of public demand for insurance coverage of the service; and g) the extent to which the service is covered by self–funded employer groups of employers in the State who employ at least 500 employees. 2. A medical evaluation including: a) the extent to which the service is generally recognized by the medical community as being effective and efficacious in the treatment of patients; b) the extent to which the service is generally recognized by the medical community as demonstrated by a review of scientific and peer review literature; and c) the extent to which the service is generally available and utilized by treating physicians. 3. A financial evaluation including an estimate of both the marginal cost and the full cost of requiring carriers to provide this coverage and reimbursement requirement, including: a) the extent to which the coverage will increase or decrease the cost of the service; b) the extent to which the coverage will increase the appropriate use of the service; c) the extent to which the mandated service will be a substitute for a more expensive service; d) the extent to which the coverage will increase or decrease the administrative expenses of carriers, and the premium and administrative expenses of policy holders and contract holders; e) the impact of this coverage on the total cost of health care; and f) the impact of all mandated health insurance services on employers’ ability to purchase health benefits policies meeting their employees’ needs.
