Insurance, Vitiligo, and You
By Dr. James Nordlund

There are a variety of treatments used commonly for vitiligo. Insurance coverage is available but variable for most of these. Insurance coverage often depends on the type of coverage. Those with very complete coverage will find obtaining treatments relatively easy. Those with limited policies will find at least some limitations on coverage for many treatments. Often insurance denies coverage. Letters appealing the decisions will reverse refusals many but not all of the time. The following comments represent feedback from patients and not a survey of the dozens of insurance plans.

1. Office visits: Insurance provides the usually office visit reimbursement but deductibles and co-pays are patient responsibility. Consultants out of plans might not be covered. On occasion referral by the primary care doctor is required for reimbursement.

2. Topical steroids: Prescriptions for topical steroids of all varieties and strengths are reimbursed. Occasionally brand names are rejected in favor of comparable generic medications that are equally effective.

3. Immunomodulators: There are two immunomodulators used to treat vitiligo. These are Protopic and Elidel. Most insurance will reimburse for one or the other, sometimes either medication. They can be substituted if a policy provides for one but not the other.

4. Dovonex: The vitamin D analogue is reimbursed if on the formulary for the policy. Occasionally it is not formulary. It is a brand drug and out of pocket expenses are higher.

5. Narrow band ultraviolet light: Most but not all insurance will reimburse for this type of ultraviolet light treatments. However the patient is responsible usually for an office visit co-pay. Most light treatments are $60-80 per treatment and the patient is expected to pay small ($10) to moderate ($40) amounts per treatment. Since these are given 2-3 times per week for as long as 6 months, the total cost to the patient can be substantial.

6. PUVA: PUVA has two components, an oral chemical called Oxsoralen and an ultraviolet light treatment. Most insurance pays for the medication Oxsoralen. Some will reimburse for the UVA, many will not if the PUVA is administered for vitiligo. In contrast most insurance covers PUVA for psoriasis. Vitiligo is considered cosmetic, psoriasis a medical problem by many insurance companies. If UVA is covered by the insurance, it follow the same rules as item #5.

7. Benoquin for depigmentation: About half of insurance companies reject this prescription but many will reconsider if a letter of appeal is written. A few are adamant and will refuse all reimbursement. Benoquin is considered cosmetic treatment. It is rather expensive.

8. Other treatments: such as vitamins, pseudocatalase, treatments from the internet. These are all considered outside of standard care and are not reimbursed. Some vitamins in higher doses by prescription such as folic acid might be reimbursed but are inexpensive.

Letters of appeal
It is worthwhile to have a letter written by the doctor appealing denials. Important elements include the following points, all of which are true.

1. Vitiligo is probably an autoimmune disorder.

2. Depigmented skin is more susceptible to sunburn.

3. Depigmented skin does not function normally.

4. The purpose of treatment is to return the skin to normal structure and function.

5. The patient does get cosmetic improvement but that should not be reason for denial since all dermatological treatments such as for acne and psoriasis also produce cosmetic improvement while improving the skin functionally.

6. Treatments are not ongoing but are for 3 to 6 months generally. At times they are intermittent and can continue longer than 6 months.

7. Especially for those with dark skin, it might be worth mentioning some egregious social event due to the visible depigmentation, i.e., rejection, embarrassing public moment, problems at work. These should appeal to the emotional feelings of the insurance reviews who would not like to suffer similar problems