Many Insurers Refusing to Pay for New Impotence Pill
Los Angeles urologist Leon Bender got a phone call from a pharmacist at 6:30 a.m. one day this week, saying the managed care insurer would not pay for a prescription for a new hot-selling male impotency pill until a testosterone test was done on the patient.
By midweek, Bender had taken calls from five insurers, each insisting that the doctor provide proof of medical necessity before they would cover a prescription for the new potency pill, Viagra.
“I think they [health insurers] are trying to slow down the process,” said Bender, whose experience is echoed by other doctors who have been swamped with patient requests for Viagra, the first oral medication to treat impotence.
That insurers are treading cautiously is no surprise.
Two weeks after its launch, Viagra is on its way to becoming one of the fastest-selling drugs in history. Doctors across the nation report that consumer demand for the $10-a-pop pill is unlike any other drug they’ve ever seen.
And for insurers, the mad rush is posing some tricky economic, medical, public relations and even philosophical issues. Insurance companies suddenly are asking the same question posed decades ago by humorists James Thurber and E.B. White in their book, “Is Sex Necessary?”
Some of the nation’s largest health plans seem unsure of the answer. Aetna U.S. Healthcare, Health Net, Kaiser Permanente and PacifiCare Health Systems all say they have decided not to pay for the pill--at least for now.
PacifiCare, the nation’s largest Medicare HMO, is refusing payment because male impotency treatment is “not a covered benefit” and is “not a medical necessity,” said spokeswoman Susan Whyte Simon.
She likened Viagra to other treatments not usually covered by insurers, such as weight-loss programs, cosmetic surgery and some infertility services. But she stressed that the health plan’s decision on Viagra is only a “preliminary ruling.”
PacifiCare says its caution is partly prompted by concerns about potential misuse of the drug. Some doctors report that they are receiving requests for Viagra from potent men who hope that the drug will rev up their sexual performance. Researchers don’t yet know whether it will.
And Viagra is being hawked on the Internet by pharmacies and people claiming to be doctors offering prescriptions by mail, apparently without requiring a physical examination or other medical work-up.
One Internet site offers a Viagra prescription after an “eight-minute” online consultation for $99--billable to the patient’s credit card.
The drug’s manufacturer, New York-based Pfizer Inc., said it is concerned that Viagra is attracting the attention of hucksters. Earlier this week, Pfizer won a federal court order to stop a Georgia company from marketing a supposed impotency treatment called “Vaegra.”
The company is opposed to the drug being prescribed over the Internet.
“We believe it is critical to have patient-doctor interaction to properly diagnose erectile dysfunction, including a sexual history, medical history and physical examination,” said David Brinkley, director of sexual health products for Pfizer. “You just can’t do a physical exam over the phone.”
Patients using nitroglycerin patches for certain conditions should not take Viagra, for example. And Brinkley noted that true impotence is often a sign of serious, potentially life-threatening illnesses, such as diabetes, heart disease or prostate cancer.
Viagra is the first nonsurgical alternative to treating impotence, a condition said to afflict up to 20 million men at some time during their lives. The new drug is taken orally an hour before intercourse, and enables men to achieve penile erections after sexual stimulation. Current treatments for impotence involve injections or devices inserted into the penis, options that are unpopular with many men.
For many patients, Viagra’s high per-dose cost makes the issue of insurance reimbursement an important one. Used twice a week before sex, Viagra would cost about $80 per month.
However, Viagra still would be less costly than other impotency treatments. Penile injections cost about $15 each, while penile implants can exceed $15,000, impotency experts say.
While some insurers reportedly are paying for Viagra, several major California HMOs said they are still reviewing safety and effectiveness data before deciding how to proceed.
“Like any new drug, it will go through an evaluation process,” said Jim Anderson, a spokesman for Kaiser in Southern California. Kaiser physicians can write prescriptions for Viagra, but patients who want the drug will have to foot the bill themselves.
Economic Considerations
Several impotency specialists suggested that insurers’ reluctance to pay for Viagra is driven more by economic considerations than medical ones. They noted that some insurers--as well as the federal government’s Medicare program--pay for other impotency treatments when there is a demonstrated medical need.
“They can’t come back and say we don’t recognize erectile dysfunction as a disorder and now won’t pay because it is like cosmetic surgery,” said Jacob Rajfer, a UCLA urologist who conducted research on Viagra for Pfizer. Noting the public clamor for the drug and the potential for angry customers, he added: “I think it’s only a matter of time before the insurers who are refusing to pay for this will change their mind.”
Ira D. Sharlip, a San Francisco urologist, insisted that it is “philosophically wrong” to compare male impotence with cosmetic surgery. “For most men and their wives or significant others, sexual function is not something that is superficial in life. . . . We do many things in medicine to improve the quality of life, even if we’re not dealing with life-threatening conditions.”
While insisting that cost “had nothing to do” with PacifiCare’s initial decision on Viagra, Simon later noted: “We have to look at how much will it cost for everybody to add these benefits.” She noted that employers may not want to pay for something perceived as “not part of a basic benefits package.”
One alternative would be to make Viagra--and other impotency drugs that are awaiting federal approval--an optional insurance benefit available to employers and individuals at an extra cost. Mental health, vision and alternative medical benefits are handled in this way.
It’s unlikely that insurers will want to pay for, say, a 30-pill monthly supply that would cost about $300 and, in theory, would allow an impotency sufferer to have sex every day. More likely, insurers would seek to limit reimbursement to a specific number of pills per month--in effect, determining how often an individual could engage in sex.
Whether insurance covers Viagra, its popularity seems likely to keep growing as long as it works. One urologist tells of an 85-year-old patient who came to the office asking for the drug. “He said, “I haven’t had an erection in five years since my wife died, and now I’m dating someone.’ ”
The patient later reported that the drug was “working fine.”
