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Table.  
Coverage of IVIG Treatment for AIBDs by the Top 10 Private US Insurers by Market Sharea
Coverage of IVIG Treatment for AIBDs by the Top 10 Private US Insurers by Market Sharea
1.
Amagai  M, Ikeda  S, Shimizu  H,  et al; Pemphigus Study Group.  A randomized double-blind trial of intravenous immunoglobulin for pemphigus.  J Am Acad Dermatol. 2009;60(4):595-603.PubMedGoogle ScholarCrossref
2.
Amagai  M, Ikeda  S, Hashimoto  T,  et al; Bullous Pemphigoid Study Group.  A randomized double-blind trial of intravenous immunoglobulin for bullous pemphigoid.  J Dermatol Sci. 2017;85(2):77-84.PubMedGoogle ScholarCrossref
3.
Daoud  YJ, Amin  KG.  Comparison of cost of immune globulin intravenous therapy to conventional immunosuppressive therapy in treating patients with autoimmune mucocutaneous blistering diseases.  Int Immunopharmacol. 2006;6(4):600-606.PubMedGoogle ScholarCrossref
4.
Bloom  R, Amber  KT.  Private and public coverage policies for rituximab in the treatment of immunobullous disease in the United States.  J Am Acad Dermatol. 2015;73(2):337-338.PubMedGoogle ScholarCrossref
5.
Wang  G, Beattie  MS, Ponce  NA, Phillips  KA.  Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling.  Genet Med. 2011;13(12):1045-1050.PubMedGoogle ScholarCrossref
6.
National Association of Insurance Commissioners. 2015 Market Share Reports For the Top 125 Accident and Health Insurance Groups and Companies by State and Countrywide. Washington, DC: NAIC; 2017. http://www.naic.org/prod_serv/MSR-HB-16.pdf. Revised January 2017. Accessed July 7, 2017.
7.
Barnett  JC, Vornovitsky  MS. US Department of Commerce Economics and Statistics Administration; US Census Bureau. Health Insurance Coverage in the United States:2015. Current Populations Report. Washington, DC: US Government Printing Office; 2016. https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf. Accessed July 7, 2017.
8.
Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) for Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases (250.3). https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=158. Accessed April 19, 2017.
Research Letter
November 2017

Coverage of Intravenous Immunoglobulin for Autoimmune Blistering Diseases Among US Insurers

Author Affiliations
  • 1Department of Dermatology, University of California, Irvine
JAMA Dermatol. 2017;153(11):1189-1190. doi:10.1001/jamadermatol.2017.2614

Treatment of autoimmune blistering diseases (AIBDs) has historically relied on systemic corticosteroids, but intravenous immunoglobulin (IVIG) has been shown in randomized clinical trials to be safe and highly effective in the treatment of pemphigus vulgaris and bullous pemphigoid.1,2 Despite its efficacy, the cost of IVIG remains a deterrent to its use. However, owing to the decrease in associated infections, complications, and hospitalizations, cost studies in the United States indicate that IVIG is an overall cost-saving therapy in the treatment of AIBD compared with traditional immunosuppressive treatment.3

Coverage for rituximab for AIBDs varies greatly, with Medicaid providing the most limited coverage.4 Given the growing body of high-quality evidence supporting IVIG’s efficacy and safety in the treatment of AIBDs, we sought to similarly evaluate coverage policies among selected private and public payers in the United States.

Methods

To determine coverage policies for IVIG, we used a modification of the protocol described by Wang et al.4,5 We identified coverage policies using the websites of each state’s Medicaid program and the Centers for Medicare and Medicaid Services. We identified the top 10 private health insurance providers by market share using the National Association of Insurance Commissioners 2015 market share report.6 Institutional review board approval was not required according to the Basic HHS Policy for Protection of Human Research Subjects (45 CFR 46). The search was performed in April 2017.

The US Department of Commerce, Economics and Statistics Administration report on health insurance coverage in the United States for 2015 was used to determine the number of Americans covered by private insurance, Medicaid, and Medicare.7 The report demonstrated 201 million privately insured individuals as well as 49 million individuals with Medicare and 54.9 million with Medicaid. Nine of the 10 private payers listed policies regarding the use of IVIG for AIBDs, accounting for 41.06% of the private market share or 82.5 million covered individuals. The Kaiser system was excluded, as it is a closed system. All Medicaid and Medicare databases were assessed. Thus, data apply to 186.4 million of 304.9 million total covered individuals (61.1%).

Results

All 9 of the private payers assessed listed AIBD as a covered disease. Data from private insurance companies are shown in the Table. Of the 51 Medicaid state or district providers, 48 were assessed. Data for New Mexico, Oklahoma, and South Dakota were not readily available. Eleven state Medicaid websites listed AIBD as an acceptable indication for the use of IVIG. In October 2002, the Centers for Medicare and Medicaid Services issued a National Coverage Determination on IVIG for AIBD, directing all Medicare vendors to cover IVIG for AIBD.8

Discussion

We herein demonstrate that although IVIG is, overall, accessible to patients with AIBD covered by private insurance or Medicare, patients with AIBD who are insured by Medicaid are often limited in their ability to receive coverage for IVIG. Because current data support IVIG as an overall cost-saving and efficacious therapy for the treatment of AIBD, Medicaid coverage of IVIG should match the policies of private payers and Medicare.

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Article Information

Corresponding Author: Kyle T. Amber, MD, Department of Dermatology, University of California Irvine Health, 118 Med Surg 1, Irvine, CA 92697 (kamber@uci.edu).

Accepted for Publication: June 3, 2017.

Author Contributions: Dr Amber had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Both authors.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Amber.

Administrative, technical, or material support: Valdebran.

Study supervision: Amber.

Published Online: August 16, 2017. doi:10.1001/jamadermatol.2017.2614

Conflict of Interest Disclosures: None reported.

References
1.
Amagai  M, Ikeda  S, Shimizu  H,  et al; Pemphigus Study Group.  A randomized double-blind trial of intravenous immunoglobulin for pemphigus.  J Am Acad Dermatol. 2009;60(4):595-603.PubMedGoogle ScholarCrossref
2.
Amagai  M, Ikeda  S, Hashimoto  T,  et al; Bullous Pemphigoid Study Group.  A randomized double-blind trial of intravenous immunoglobulin for bullous pemphigoid.  J Dermatol Sci. 2017;85(2):77-84.PubMedGoogle ScholarCrossref
3.
Daoud  YJ, Amin  KG.  Comparison of cost of immune globulin intravenous therapy to conventional immunosuppressive therapy in treating patients with autoimmune mucocutaneous blistering diseases.  Int Immunopharmacol. 2006;6(4):600-606.PubMedGoogle ScholarCrossref
4.
Bloom  R, Amber  KT.  Private and public coverage policies for rituximab in the treatment of immunobullous disease in the United States.  J Am Acad Dermatol. 2015;73(2):337-338.PubMedGoogle ScholarCrossref
5.
Wang  G, Beattie  MS, Ponce  NA, Phillips  KA.  Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling.  Genet Med. 2011;13(12):1045-1050.PubMedGoogle ScholarCrossref
6.
National Association of Insurance Commissioners. 2015 Market Share Reports For the Top 125 Accident and Health Insurance Groups and Companies by State and Countrywide. Washington, DC: NAIC; 2017. http://www.naic.org/prod_serv/MSR-HB-16.pdf. Revised January 2017. Accessed July 7, 2017.
7.
Barnett  JC, Vornovitsky  MS. US Department of Commerce Economics and Statistics Administration; US Census Bureau. Health Insurance Coverage in the United States:2015. Current Populations Report. Washington, DC: US Government Printing Office; 2016. https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf. Accessed July 7, 2017.
8.
Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) for Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases (250.3). https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=158. Accessed April 19, 2017.
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