Heather Woolery-Lloyd, MD: Now, [Dr Owens], let’s talk a little bit about the payer perspective and how ruxolitinib fits into the treatment pathway from a payer perspective.

Gary M Owens, MD: That’s a great question. Again, prior to 2022, we had topical ruxolitinib. Payers really didn’t give much thought to vitiligo. Yes, we had occasional patients, as you noted in this discussion, who were getting phototherapy, who we authorized phototherapy treatments for. But other than that, with the TCIs [target-controlled infusions] and topical corticosteroids, those are all we used off-label for vitiligo. They were generic for the most part, and not being managed by patients. Fast-forward to 2022 and I agree, ruxolitinib was a breakthrough because now we have the first targeted immunomodulatory agent. As [Dr Kindred] pointed out, corticosteroids are great, but they’re like treating a disease with a shotgun. You basically blast every aspect of the immune system and get a lot of unwanted effects.

Initially payers were somewhat concerned about the potential for cost of a therapy that was newer and more expensive. On the other hand, vitiligo is not a huge disease. It’s not like diabetes, where 10% [or more] of your population is going to have it if they’re over 65. That could approach 30% of your population. And as I’ve heard everyone say, many of these patients have had this disease for years. They’re very savvy. They’ve tried everything else. Putting in a pathway that makes people go through a calcineurin inhibitor, which as we’ve heard is not terribly effective, safe on the face, of course, but otherwise not terribly effective, and corticosteroids, which work but you don’t want to use on the face. It makes less sense for payers to have existing patients, in particular, step through the older therapies because they’ve already had them at some point in their life and many of them have given up and maybe, as you pointed out, come back in a year to see if there’s anything new.

I think we’re seeing an evolution of treatment. Ruxolitinib is still going to be prior authorized by most payers just because of the cost and [because] it fits into the specialty pharmacy benefit. Which just leads me to 1 comment, because you made the comment on phototherapy, that the out-of-pocket costs of paying a co-payment of $40 or $50 more than once a week can be expensive. Paying a co-insurance, which is a percentage of the cost of the drug, can be expensive for people who are on topical ruxolitinib. There are some barriers there to people, especially those with comorbid conditions who may be getting a lot of other therapies. Maybe $25 or $30 doesn’t seem like much, but if you’re on 7 medicines and each of them is $30, that adds up very quickly. What I’m really getting at is payers are getting away from any treatment pathways in vitiligo. They still are prior authorizing ruxolitinib, and it’s still in a specialty tier simply because of the monthly cost.

Heather Woolery-Lloyd, MD: That’s exciting to me that there is a little bit of a pullback from having to jump over these hoops because a lot of these patients have had vitiligo for so many years. That’s very encouraging that payers are allowing patients to get this as first-line therapy. I love that you mentioned costs. I’m very sensitive to costs for my patients. I agree with you. It’s a $30 co-pay and $30, actually, to me, sounds great. Usually, a lot of co-pays are more than $30.

Gary M Owens, MD: They can be $60, $70, $80, for sure.

Heather Woolery-Lloyd, MD: Yeah, and I think that it’s something that we really do need to consider because I’m very sensitive to the economic impacts of our skin diseases, where we do tend to write quite a few prescriptions. In dermatology, someone comes in and can walk out with 3, 4, or 5 different prescriptions because maybe in addition to their vitiligo they might have acne, or they might have a little eczema, or something else. It can add up. But it is exciting to hear that we don’t need to jump over these hoops, because this is something that is the first FDA-approved treatment for vitiligo and the only FDA-approved treatment. It’s something that I think is exciting for our patients. They’re willing, even if there is a high co-insurance, to make that investment, if they have to.

Gary M Owens, MD: I think where the real challenge will come in will be 5 or 6 years down the road. We have multiple therapies, and how that aspect is going to be managed, I’m not sure I have that answer yet, but it’s an interesting concept.

Transcript edited for clarity.