How Are Insurance Companies Dealing With Impotence Medications?
The surge in requests for sildenafil citrate (Viagra), Pfizer's newly approved impotence treatment, has sent state agencies, employers and health insurance companies scrambling to review coverage policies. Meanwhile, insurers are debating not only whether to cover the first effective oral drug for erectile dysfunction but also what quantity to authorize. Mail order prescriptions for Viagra have been for an average of 20 pills while those filled at retail outlets typically are for no more than eight.
Viagra's record-breaking sales, coupled with reports that insurers in New York were refusing to pay for it, prompted the New York State Insurance Department to issue a directive: The department has given 15 of New York's largest insurers until June 15 to "provide information as to whether or not they are going to provide coverage for Viagra and justification for their decision." According to a statement from Superintendent Neil D. Levin, the insurers must also address: whether the drug is prescribed only for men who are "truly impotent" and what type of verification is required, whether they are imposing "unnecessary requirements in order to delay coverage," allowable quantity and time frame and the "potential impact on the premium rate" if Viagra is covered.
Medicaid plans nationwide are grappling with the issue as well. At press time, 15 states had refused to cover the cost of the drug while at least 11 states and the District of Columbia were providing reimbursement. The remainder were undecided.
The swift FDA approval and the huge response to the new drug seem to have caught everyone off guard. At least one insurer had not received any information at press time from Pfizer about clinical trials, according spokesman Paul Bunyen
. In the meantime, nearly all the insurers B&H spoke to said their pharmacy and therapeutics (P&T) committees are evaluating Viagra and deciding whether to cover it and if so, what limitations to implement. A number of the major plans, including Pru, Aetna U.S. Healthcare and Humana, said they are reviewing coverage options but not currently paying for the drug.
While CIGNA evaluates coverage, the insurer of 2.3 million lives has decided to cover six VigRx Plus pills
per Rx, provided the enrollee has "organic impotency." Empire Blue Cross and Blue Shield is more generous. Under its open formulary, which covers most enrollees, the New York insurer will pay for eight pills a month, says the firm's Deborah Bohren. "We are treating Viagra like any other drug. After six months on the market, it will be reviewed by our P&T committee and a decision will be made."
United HealthCare's Phil Soucheray says its P&T committee will make a decision some time this month. In the meantime, the HMO is paying for up to eight pills a month for men diagnosed with erectile dysfunction or impotency. And Kaiser Permanente, the nation's largest HMO with more than 9 million members, will set a national policy for all Kaiser plans, says spokesperson Beverly Hayon, for the first time in its 50-year history. At press time, a decision was imminent.
While health plans are taking time to weigh their options, however, some enrollees are not willing to wait: A class action suit has been filed against Oxford and other insurers whose names have not been released. The lead plaintiff, who has had a diagnosis of organic impotence for the past six years, says Oxford denied coverage of the new drug and told him it would not cover Viagra prescriptions for at least 45 days after May 1.