Citing Costs, Many Big Insurers Won't Pay for Viagra
NYT, 6/20/98
Some of the nation's biggest health insurers have decided not to pay for Viagra, the male impotence drug, under their prescription drug plans. They said that providing the recommended 6 to 12 pills per month would be too expensive, adding hundreds of millions of dollars to annual costs.
The drug has been promoted as an important enhancement to the quality of life for many older men and their wives, but some health economists have raised questions about the medical necessity of a treatment for impotence and the expense relative to other drugs.
Kaiser Permanente, the nation's largest nonprofit health maintenance organization, announced Friday that Viagra would only be available as an extra benefit at an additional cost to employer groups, or to individuals who buy it with their own money at Kaiser pharmacies. ?
Kaiser, which has 9.1 million members in 19 states, said the cost of covering Viagra would have exceeded $100 million a year. Many Kaiser members are older men who are believed likely to request the drug.
Aetna U.S. Healthcare, another big insurance company, told New York insurance officials this week that it would not cover Viagra, except as an option at extra cost. Aetna estimated that covering Viagra could add $50 million to its costs.
Medicaid officials in a number of states, including New York, have said they would not cover Viagra unless federal Medicaid officials required it. Officials in Washington have said they did not expect to require coverage when a doctor said Viagra was medically necessary.
Pfizer Inc., which makes Viagra, said many other insurers were covering the drug. Patrick Kelly, a senior vice president of the Pfizer Pharmaceutical division, said 2 million prescriptions had been filled since Viagra went on sale in pharmacies in mid-April.
Pfizer said big insurers covering Viagra included Blue Cross and Blue Shield plans in California and Indiana, the NYLcare unit of the New York Life Insurance Co. and Harvard Pilgrim Health Care, based in Massachusetts, as well as the Defense Department health plan.
United Healthcare Corp., also a big national insurer, said it had adopted an "interim" policy of approving eight pills a month. Several big companies said they had not decided what to do about Viagra.
Merck-Medco, a unit of Merck & Co., which sells drugs and manages drug benefits for health plans, advised 1,100 customers to limit coverage to 12 pills a month. Medco spokesman Kevin Colgan said a survey by its sales staff found a variety of policies, ranging from unlimited coverage to exclusion, as well as requirements that physicians get approval before prescribing Viagra.
Pfizer said it had recommended 10 pills a month, based on results during its tests of the drug. But Kelly said six a month was the number covered by most health plans.
Kaiser Permanente spokeswoman Beverly Hayon said the issue was "the affordability of health care." After a bruising struggle over costs with the California Public Employees Retirement System, Kaiser's biggest customer, the health maintenance organization reduced a proposed rate increase to 10.75 percent from the 12 percent it originally sought, in a compromise announced this week. Ms. Hayon said Kaiser's estimate of $100 million a year to cover Viagra was conservative.
She said the California pension fund had also decided to exclude coverage of Viagra from its big self-insured health care networks, which are separate from the Kaiser plans.
A spokeswoman for the New York state Health Department had a different reason for excluding Viagra coverage. The spokeswoman, Frances Tarlton, said that because of the great demand for Viagra, it had a potential for abuse, including being sold on the street by people who obtained it from Medicaid.
Mary Sevon, a pharmacy benefits consultant in Fairless Hills, Pa., said the cost of Viagra would vary according to the age of a health plan's members. For a Medicare plan, she said it could be as high as $60 per member per year. For plans with younger members, and therefore lower demand for the drug, the cost might be as low as $5 to $12 a year.
|
