The scope of health insurance coverage of vitiligo treatments in the United States: Implications for health care outcomes and disparities in children of color

Abstract

Background Patients of color are disproportionately impacted by vitiligo. Access to treatment depends greatly on insurance coverage. We, therefore, assessed current vitiligo treatment coverage policies across major United States health insurers to determine current patterns and coverage gaps for vitiligo. Methods The study surveyed 15 commercial health care insurers, 50 BlueCross BlueShield (BCBS) plans, Medicare, Medicaid, and Veterans Affairs. Information on treatment coverage for vitiligo, specifically pimecrolimus and tacrolimus, excimer laser therapy, PUVA, and narrow‐band (nb)UVB, was collected via an online review of insurance policy documents, confirmed with phone calls to organization representatives, or via a survey of Medicaid providers, and state Medicaid directors. Results Of 17 organizations with regional or national coverage policies, 12% did not cover topical calcineurin inhibitors, 56% did not cover nbUVB phototherapy, 53% did not cover PUVA phototherapy, and 41% did not cover laser therapy. For BCBS, pimecrolimus and tacrolimus were not covered in 39% and 35% of states, respectively. NbUVB and PUVA therapy were not covered in 20% and 10% of states, respectively. Excimer laser therapy was not covered in 82% of states. Out of 32 states with accessible Medicaid information, 11 did not cover topicals, 5 did not cover nbUVB, 4 did not cover PUVA, and 7 did not cover laser. Two commonly cited reasons for coverage denial were that the treatment indication was considered cosmetic, and certain therapies are not FDA‐approved. Conclusions There is inequity in the distribution of health among vitiligo patients given current patterns of insurance coverage for treatment, which may have disproportionate impact on patients of color.

Vitiligo

“…1 In July 2022, ruxolitinib cream 1.5% was approved by the US Food and Drug Administration (FDA) for nonsegmental vitiligo in patients 12 years and older. 6,7 It is the only FDA-approved therapy for vitiligo. It is thought to work by inhibiting the Janus kinasesignal transducers and activators of the transcription pathway.…”

“…There were 2 commonly cited reasons for denying coverage for therapies: vitiligo was considered cosmetic and therapies were not FDA approved. 7 In comparison, NB-UVB light phototherapy for psoriasis is not considered cosmetic and has a much higher insurance coverage rate. 9,10 The out-of-pocket cost for a patient to purchase their own NB-UVB light phototherapy is more than $5000.…”

Vitiligo

“…1 In July 2022, ruxolitinib cream 1.5% was approved by the US Food and Drug Administration (FDA) for nonsegmental vitiligo in patients ages 12 years and older. 6,7 It is the only FDA-approved therapy for vitiligo. It is thought to work by inhibiting the Janus kinase-signal transducers and activators of the transcription pathway.…”

“…There were 2 commonly cited reasons for denying coverage for therapies: vitiligo was considered cosmetic and therapies were not FDA approved. 7 In comparison, NB-UVB light phototherapy for psoriasis is not considered cosmetic and has a much higher insurance coverage rate. 9,10 The out-of-pocket cost for a patient to purchase their own NB-UVB light phototherapy is more than $5000.…”

Double Standards and Inconsistencies in Access to Care—What Constitutes a Cosmetic Treatment?

“…For instance, although vitiligo is associated with stigmatization and depression, particularly among racial and ethnic minority groups, 2 a 2021 cross-sectional evaluation of coverage for vitiligo treatments among more than 65 public and private payers found that 12% did not cover topical calcineurin inhibitors and over half did not cover phototherapy, with the most common reason for denial being that vitiligo is considered a cosmetic condition. 3 A recent analysis of claims data found that most patients with rosacea and melasma were unable to access first line treatments and that patients with melasma were 26-fold less likely to access treatments compared with those with rosacea. 4 Furthermore, treatments for inflammatory papules of rosacea (eg, topical metronidazole) are covered much more frequently than treatments for redness and flushing of rosacea (eg, topical brimonidine), even though flushing can cause burning and irritation that could be considered to reflect a disturbance of sensation.…”