HMO Need Not Pay for Viagra, Judge Decides

California regulators cannot force the state’s biggest HMO to pay for anti-impotence drug Viagra, a judge has ruled in a decision that might affect prescription coverage by other health plans.

The state Department of Managed Health Care had required Kaiser Permanente to provide coverage of Viagra and other sexual-dysfunction drugs.

But Sacramento County Superior Court Judge Lloyd Connelly said state law didn’t require health plans to cover all prescription drugs or to provide drugs for conditions not covered by health plan members’ insurance contracts.

“We are very pleased by the decision,” Kaiser Permanente spokesman Jim Anderson said Tuesday, adding that it was hard to say how the decision would be implemented. “We believe that it vindicates our basic position that California law allows health plans to design different kinds of pharmacy benefits.”

Although Friday’s ruling applies only to Viagra, some said it could affect coverage of other so-called lifestyle drugs for conditions such as baldness or obesity.

“Practically speaking, we think this decision only affects Viagra, but it may have implications in the future,” said Steven Fisher, spokesman for the state Department of Managed Care.

Viagra is made by Pfizer Inc.

Oakland-based Kaiser Permanente, the biggest nonprofit health maintenance organization, asked state regulators for permission in 1998 to exclude sexual dysfunction drugs such as Viagra from its formulary, the list of medications for which it routinely pays. The HMO said the large number of men seeking prescriptions for the drug threatened to drive up its costs by $100 million a year.

The state refused the HMO’s request and opened an investigation into whether dropping coverage because of economic considerations was in violation of state law. California regulators have authority over HMOs that operate in the state.

Consumer advocates also had complained that the move to refuse Viagra coverage was an unlawful attempt to boost profit at the expense of patients’ health and could pave the way for HMO programs to eliminate other drug benefits because of cost.

In 1999, the HMO worked out an agreement with the state that it would pay for 50% of the cost of treatment.

But Connelly ruled that Kaiser Permanente was within its rights to exclude Viagra.

Anderson said it is too soon to say whether the judge’s ruling would spell the end for program coverage for other sexual dysfunction drugs.

Kaiser Permanente has 6.2 million members in California.