A genetic test for mutations in the BRCA1 and BRCA2 genes can provide significant information regarding the lifetime risk for breast, ovarian, and other cancers. The process involves a simple blood or saliva sample analysis, yet the true financial liability for this testing is complex and highly variable. The amount a person ultimately pays is not determined by a fixed price but by a series of factors, including the testing laboratory, the individual’s insurance plan, and whether they meet specific medical criteria for coverage. Calculating the final cost requires understanding the difference between the full retail price and the discounted rate, as well as the terms of one’s health coverage.
Understanding the Uninsured List Price
The maximum price charged for a comprehensive BRCA test is known as the uninsured list price or “sticker price.” This retail cost is what an individual without any insurance coverage or financial assistance would be billed directly by the laboratory. For a full sequencing and rearrangement analysis of both the BRCA1 and BRCA2 genes, this list price can range from approximately $1,500 to over $3,000.
This maximum price is rarely the final amount paid by most individuals, but it represents the cost before any negotiation or discount. The price variation often reflects whether the test is a targeted analysis for a known family mutation or a broad panel testing many genes beyond just the BRCA pair. Laboratories set these high list prices, which are then significantly reduced through contracts with insurance carriers.
Criteria for Insurance Coverage
The single greatest factor in reducing the cost of a BRCA test is whether it is deemed “medically necessary” and covered by a health insurance plan. Insurers rely on guidelines established by professional bodies, such as the U.S. Preventive Services Task Force (USPSTF) and the National Comprehensive Cancer Network (NCCN). These guidelines define the specific personal and family histories that warrant genetic testing.
Common Coverage Criteria
A common criterion for coverage is a personal history of certain cancers, which includes breast cancer diagnosed at a young age, ovarian cancer at any age, or male breast cancer. The insurance company’s approval is also likely if there is a known BRCA mutation already identified in a close blood relative. Family history patterns that increase the likelihood of coverage include two or more close relatives with breast cancer, or a relative diagnosed with both breast and ovarian cancer.
The guidelines also recognize that certain ancestries carry a higher risk, such as individuals of Ashkenazi Jewish descent, who have a greater probability of having one of the three common founder mutations. When a patient meets these defined criteria, the test is covered because the result will directly influence medical management and preventative care decisions. If a person does not meet these strict medical necessity requirements, the insurance company will deny coverage, leaving the individual responsible for the cost.
Calculating Your Actual Out-of-Pocket Cost
Even when a BRCA test is approved and covered by insurance, the patient is still responsible for a portion of the cost based on their specific plan benefits. This actual out-of-pocket amount is calculated using three primary insurance terms: the deductible, the copayment, and coinsurance.
Deductibles, Copayments, and Coinsurance
The deductible is the fixed dollar amount a patient must pay out of pocket each year before the insurance company begins to pay for covered services. If the test is performed before the deductible is met, the patient will pay the full contracted rate for the test, which is significantly lower than the list price.
Once the deductible is satisfied, copayments or coinsurance amounts come into effect. A copayment is a fixed fee, such as $50, that the patient pays for a covered service. Coinsurance is a percentage of the total allowed cost for the service, meaning the patient might pay 10% or 20% of the cost while the insurer covers the remainder.
The patient’s out-of-pocket obligation for BRCA testing is often dictated by their health plan’s rules regarding specialty lab work. Some preventive services, including genetic counseling and testing for women who meet USPSTF criteria, may be covered with no out-of-pocket costs under the Affordable Care Act. However, for those with high-deductible plans or those who do not meet the full preventive criteria, the final bill can still be substantial, even with insurance coverage.
Patient Assistance Programs and Cost Reduction Strategies
For individuals who are uninsured, have high-deductible plans, or are denied coverage, several strategies exist to reduce the financial burden of a BRCA test.
Laboratory Assistance and Self-Pay Options
Many large genetic testing laboratories offer patient assistance programs designed to provide testing at a significantly reduced rate or even for free. These programs are typically income-based and require the submission of financial documentation to prove eligibility.
Many laboratories also offer a predetermined “self-pay” rate for patients who are paying out-of-pocket, which is often around $250. This discounted price is substantially less than the list price and is intended to make testing accessible to those without coverage or those who choose not to use their insurance.
Other Cost Reduction Methods
Patients can work with their healthcare providers to explore low-cost options through non-profit clinics or research studies that may offer free or reduced-cost testing for eligible participants. If a bill is received, contacting the billing department of the testing laboratory to negotiate a payment plan or a further discount is a common and often successful cost reduction strategy. Genetic counselors are trained to help navigate these financial complexities and determine the most cost-effective path to testing.