Harvard Pilgrim puts limit on Viagra
HMO to pay for only four pills per month
By Alex Pham, Globe Staff, 06/12/98
or impotent men, Viagra represents a revolutionary cure.
For insurance companies, Viagra is a nightmare.
The little blue pill is undeniably effective at treating male impotence. But it's also expensive. At $7 a pill, Viagra is a potential budget buster that threatens to plunge health maintenance organizations nationwide deep into the red.
Harvard Pilgrim Health Care yesterday took a cautious step toward dealing with the nightmare by announcing it will pay for only four pills per month for every patient diagnosed with impotence. The new allotment, which begins Monday, will replace Harvard's current policy of paying for 10 pills a month.
The decision puts Harvard Pilgrim in the difficult position of having to answer the question: Why four pills? Why not eight, or 12?
''It's an extraordinarily difficult issue for HMOs,'' said Robert Hoehn, health insurance analyst with Furman Selz in New York. ''They're almost getting into the business of rationing sex.''
Dr. Joseph Dorsey, in making the announcement for Harvard Pilgrim, tried to fend off any perceptions his health plan was meddling into people's sex lives.
''I don't want to be in the position of saying how often people should have intercourse,'' said Dorsey, Harvard Pilgrim's medical director. ''We are not telling physicians they can only write prescriptions for four pills. They can write for 30 or 90 or whatever. What we are saying is that we will only pay for four a month. ''
In the first month after Viagra hit pharmacy shelves in late March, Harvard Pilgrim's bill for the drug was around $400,000.
Mindful of the huge costs, other health plans have set similar constraints on Viagra. Tufts Health Plan limits use to four treatmentsa month for men diagnosed with erectile dysfunction. Fallon Community Health Plan also pays for four treatments, but only after physicians apply to the HMO's ''compassionate use'' program. Blue Cross and Blue Shield of Massachusetts has the most generous allotment of the group, allowing each patient 12 pills a month. The number of pills per treatment can vary.
As to why Harvard Pilgrim settled on four pills as opposed to, say, eight, Dorsey admits there is no scientific logic to that number. ''It demonstrates a commitment to using the resource pool to help make it possible for people to use the medicine,'' he said. ''But it also reflects the fact that Viagra is too expensive for us to pay for unlimited use.''
Hoehn of Furman Selz said Harvard Pilgrim is venturing into unfamiliar terrain. ''Everyone is at a loss on this one,'' Hoehn said. ''If you cover it, your premiums will probably have to go up to help pay for it. If you don't, you run the risk of being sued or being upstaged by a competitor who will cover it.''
Oxford Health Plans Inc., in Trumbull, Conn., was hit last month with a $10 million lawsuit from a patient who challenged the company's refusal to cover Viagra.
Aware of these risks, Harvard Pilgrim is floating the decision as a trial balloon; it promises to reevaluate its policy in six months. In the meantime, it is closely monitoring public reaction to the new policy.
Viagra is unlike many other drugs, for which dosage and frequency of useare fairly well defined and predictable within a certain range. With Viagra, there are no medical guidelines. Thus, patients can theoretically ask for just one pill or up to as many as 90 a month.
Physicians greeted Harvard Pilgrim's decision with faint praise.
''At least they're covering something,'' said Dr. Andre Guay, director of Lahey Clinic's Center for Sexual Function in Peabody. Guay, an endocrinologist, was paid by Pfizer Inc., the manufacturer of Viagra, to perform clinical trials of the drug.
This story ran on page of the Boston Globe on 06/12/98.
c Copyright 1998 Globe Newspaper Company.
|
