Breast cancer genetic testing identifies inherited mutations, such as those in the BRCA1 and BRCA2 genes, which significantly increase the lifetime risk of developing breast, ovarian, and other cancers. This testing provides an accurate risk assessment, allowing patients and providers to make informed decisions about cancer prevention strategies. The cost of this service is a major consideration, as the final out-of-pocket expense varies dramatically. Costs can range from nothing to thousands of dollars, depending on the test type, the laboratory, and the patient’s insurance coverage.
The Baseline Price of Genetic Testing
The list price for breast cancer genetic testing, before insurance or financial aid, ranges widely from approximately $250 to over $5,000. This variation is determined by the scope of the genetic analysis performed. Single-gene testing, which focuses exclusively on BRCA1 and BRCA2 mutations, represents the lower end of the cost spectrum, often priced between $250 and $1,500 for a self-pay rate.
Higher costs are associated with large multi-gene panel tests, which analyze BRCA1, BRCA2, and dozens of other genes linked to hereditary cancer risk, such as ATM, CHEK2, and PALB2. These comprehensive panels require extensive sequencing and analysis, costing between $1,500 and $5,000 or more. Commercial laboratories, including Myriad, Invitae, and Color, set their own pricing structures, contributing to the overall price variation. The baseline cost may also include separate fees for professional services, such as consultation with a genetic counselor, though the lab test accounts for the majority of the expense.
Insurance Coverage and Out-of-Pocket Costs
For most patients, the final price is determined by their health insurance policy, which only covers the test if specific medical necessity criteria are met. Providers, including commercial plans, Medicare, and Medicaid, generally require a personal history of breast or ovarian cancer, a strong family history, or belonging to a high-risk group, such as individuals of Ashkenazi Jewish descent. Meeting these criteria is necessary to secure pre-authorization, which is the insurer’s formal approval that the test will be covered.
Coverage rules differ significantly across public and private plans, creating a patchwork of patient responsibility. The Affordable Care Act (ACA) mandates that certain women meeting U.S. Preventive Services Task Force (USPSTF) criteria must have BRCA counseling and testing covered with no out-of-pocket costs, provided the services are received from an in-network provider. This full coverage often does not extend to multi-gene panels or to men, for whom deductibles, copayments, and coinsurance typically apply. Medicare, for example, maintains stricter coverage criteria, often requiring the patient to have a personal history of cancer before covering the cost of genetic testing.
Even when the test is covered, a patient’s out-of-pocket costs are influenced by their plan’s financial structure. A deductible is the amount paid annually before insurance begins to pay, which can be thousands of dollars for high-deductible plans. A copayment is a fixed dollar amount paid for a service, while coinsurance is a percentage of the total cost the patient is responsible for. If an insurer denies coverage, often citing the test was “not medically necessary,” the patient is typically responsible for the full list price.
The denial of coverage is common but often appealable. A denial letter usually specifies the reason, and if it is “not medically necessary,” the ordering physician or a genetic counselor can submit an internal appeal. This process involves providing additional clinical documentation to demonstrate why the patient meets the insurer’s coverage policy or why the case is an exception. If the internal appeal is unsuccessful, patients have the right to request an external review by an independent organization.
Financial Assistance and Cost Reduction Options
Patients who are uninsured, underinsured, or facing high out-of-pocket costs have several options to reduce their financial burden. Most large commercial genetic testing laboratories offer robust Patient Assistance Programs (PAPs) designed to help eligible individuals. These programs often include capped costs, sliding scale fees, or free testing for low-income patients who meet specific financial and medical criteria.
For patients whose insurance denies coverage, many laboratories automatically cap the out-of-pocket expense at a low self-pay rate, often advertised as $250 or less. This reduces the risk of being billed the full list price of several thousand dollars. Non-profit organizations, such as the Patient Advocate Foundation or those dedicated to hereditary cancer, can also provide financial support or grants to help cover testing costs.
Some patients consider direct-to-consumer (DTC) testing options, which are generally lower in cost and available without a physician’s order. However, these tests often have limitations, such as only screening for a small number of BRCA variants, and they may not be comprehensive enough for clinical decision-making. Individuals should also inquire about price negotiation directly with the testing lab, especially after an insurance denial, as labs are often willing to accept a reduced self-pay rate rather than pursuing the full amount.