This sample letter of medical necessity for vitiligo treatment is designed to be adapted to suit the specific needs of the medical practice, physician, patient, and insurance carrier. This resource can be downloaded as an editable Word document.
Additional letters of medical necessity are available with language that is specific to other treatments such as home phototherapy and excimer laser. This resource is designed to address ruxolitinib therapy specifically.
GVF wishes to acknowledge that Incyte Corp, maker of ruxolitinib (Opzelura), is a financial supporter of the Global Vitiligo Foundation. We are posting this letter of medical necessity (LOMN) because this is the first, and currently the only, FDA-approved drug for vitiligo repigmentation, and not because they are a financial sponsor. As other drugs are approved by the FDA, we will review the data and, if warranted, create a LOMN for that drug as well.