Insurance shortfalls curb pigmentary disorder treatment, often in skin of color

Key takeaways:

• Tretinoin was covered by Medicaid in 45 states for acne, but in only 10 states for melasma and hyperpigmentation.
• Lack of coverage is mainly due to the classification of pigmentary disorders as cosmetic.

Medicaid coverage for tretinoin is often granted for acne vulgaris but not pigmentary disorders, which disproportionately affect patients with skin of color, according to a study. Healio spoke with a dermatologist about these findings.

“A lot of dermatologists are already aware that if they try to prescribe tretinoin for pigmentary disorders, particularly for patients on public health care, it likely won’t get covered,” Nicholas Theodosakis, MD, PhD, instructor in dermatology, Massachusetts General Hospital, Harvard Medical School, told Healio. “As a result, these patients, who for the most part don’t have very high incomes, are forced to pay out of pocket.”

On the other hand, Medicaid coverage for acne vulgaris is often unquestioned, leading researchers to wonder what the differences are in coverage for pigmentary disorders, such as melasma and post-inflammatory hyperpigmentation (PIH) compared with acne. In this study, Theodosakis and his colleagues set out to evaluate just that.

The researchers used data from online publicly available preferred drug lists, prior authorization criteria and email and phone inquiries to find information on coverage restrictions across all 50 states. Ultimately, they were able to find complete and partial coverage information from 30 and 16 states, respectively, whereas no information was retrievable from five states.

Results showed that of the states reporting tretinoin coverage data, 45 states covered the treatment for acne vulgaris and only 10 states covered the treatment for melasma and PIH. Furthermore, of those states that do provide coverage for pigmentary disorders, the clinical criteria for coverage of topical tretinoin targeted the epidemiology of acne vulgaris.

In other words, the age restrictions and prior authorization criteria for tretinoin coverage mimic the epidemiology of acne vulgaris which occurs in adolescence and mid-20s. However, the average onset of melasma does not begin until age 30 to 38 years resulting in a large proportion of patients with pigmentary disorders being ineligible for coverage even in the states that provide tretinoin coverage in this indication. Additionally, the majority of patients affected by pigmentary disorders tend to be patients with skin of color.

“Traditionally, pigmentary disorders don’t as heavily impact Caucasians as they do people with skin of color,” Theodosakis told Healio. “Disorders of pigmentation are also often less distressing to people with lighter skin tones because they often don’t show up as strongly in lighter complexions.”

As a result, many patients with skin of color on Medicaid do not have equal access to treatment for a condition that primarily affects darker skin tones.

According to Theodosakis, he and his colleagues thought they may be able to find a blue and red state divide in terms of which states would cover tretinoin for pigmentary disorders; however, they were surprised to find the opposite.

“Blue states in theory frequently have more expansive Medicaid programs than red states, but funny enough, we found that it ended up being the opposite,” he told Healio. “It’s interesting to emphasize that this really isn’t a political issue and it’s the sort of thing that I think red and blue states can get behind.”

So, if not a political issue, why is it that insurance companies will cover tretinoin for acne but not for pigmentary disorders? The primary answer is that insurance considers pigmentary disorders a cosmetic issue rather than a medical issue, according to Theodosakis; however, he believes that this shouldn’t be the case.

“I tend not to like the term cosmetic in general because I think everything that affects your appearance is a medical issue at some point,” he told Healio. “Additionally, hyperpigmentation isn’t something that just happens to everybody.”

According to Theodosakis, the distinction between something that could be considered exclusively cosmetic vs. medical is whether it occurs as a natural part of aging.

“Wrinkles and skin tone changes due to age happen to everybody more or less across the board,” he explained. “But something like melasma or even vitiligo selectively affects only a handful of people and is something you can safely classify as a disease, not as normal aging.”

For next steps, Theodosakis recommends the urging of state insurance carriers to review the data for pigmentary disorders and choose “at least a few” cost-effective therapies for these indications and consider expanding the age range for tretinoin coverage.

“If we’re going to classify it as a disease of any kind, it merits coverage,” Theodosakis concluded. “Based on that viewpoint, we should expand coverage and treat it like we would any other disease.”