Medicaid Programs Told To Pay For Viagra But Monitoring Continues
July 02, 1998 1:04 AM
By Laurie McGinley, Staff Reporter of The Wall Street
Journal
WASHINGTON -- Federal health officials are notifying
states that their Medicaid programs must pay for Viagra,
but they may eventually drop the requirement if a new
monitoring system shows the drug "is subject to clinical
abuse or inappropriate use."
The new federal policy is outlined in a letter from
Nancy-Ann DeParle, the administrator of the Health
Care Financing Administration, to Govs. Lawton Chiles
of Florida and Michael Leavitt of Utah. Ms. DeParle's
letter, which is to go to the governors today, is a
response to a May letter from the governors in which
they argued that the states should decide whether
Medicaid covered the high-priced impotence drug.
Ms. DeParle told the governors that, with few
exceptions, federal law requires that Medicaid, the
state-federal health program for the poor and disabled,
cover federally approved drugs prescribed for medically
approved uses. But, she said, the law allows federal
officials to exempt certain drugs after determining, based
on evidence from the states, that the medications are
being abused or improperly used.
Health and Human Services Secretary Donna Shalala "is
greatly concerned about the potential for clinical or
financial abuse of Viagra," Ms. DeParle wrote.
Therefore, HCFA will set up "a rigorous system," which
will include state officials, physicians and consumer
advocates, to monitor Viagra's use, she said.
The goal will be to determine whether Pfizer Inc.'s
blockbuster drug should be placed on the list of drugs
that don't have to be covered by Medicaid. Currently,
fertility, baldness and smoking-cessation drugs are
among those on the list of exempt medications.
In the meantime, Ms. DeParle urged state officials to
strongly consider imposing restrictions on Viagra "to
ensure appropriate use and cost efficiencies." Those
include limiting the number of refills or the number of pills
in each prescription; establishing prior-authorization
programs to ensure that physicians prescribe the drug
correctly and disciplining doctors who prescribe Viagra
when not medically necessary.
The federal directive is sure to disappoint the governors,
who warned in their May letter that hot-selling Viagra
could increase Medicaid costs by $100 million a year.
That estimate has been greeted with some skepticism by
the Clinton administration, although no one has a good
estimate of the drug's costs.
Of the 37 million people enrolled in Medicaid, only
about four million are men, and only a small subset
would be interested in the drug. Medicare, the program
for the 39 million elderly and disabled, doesn't cover
prescription drugs.
The states, while awaiting federal guidance on whether
their Medicaid programs must cover Viagra, have
reacted in different ways. South Carolina, Virginia and
Tennessee have declined to cover the drug, while
Arkansas, Alabama, Florida and Texas are paying for it,
though with some restrictions. Some big health insurers,
such as Kaiser Permanente, have also decided against
covering Viagra. The question of adverse drug
interactions, especially with some heart medications, also
has raised some questions about the drug.
But some consumer advocates have protested coverage
restrictions, saying that the drug allows men who have
had prostate cancer and spinal-cord injuries to resume
normal sex lives.
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