VIAGRA: New York Wants Coverage Guidelines From Insurers
New York state insurance officials "yesterday told insurance companies to come up with guidelines to deal with the unprecedented demand for Viagra," Pfizer's "sex pill that has grabbed an astonishing 94% of the impotence-remedy market." According to the New York Daily News, the state "wants to be sure men who need Viagra get it -- but not men who want just to pep up their sex lives." Insurance Department spokesperson John Calagna said, "We saw companies all over the lot on this issue. We expect them to be reasonable and responsible about whether they're going to provide coverage or not." The state gave New York's largest private insurers until June 15 to address five points: that "Viagra is prescribed for men who are 'truly impotent'"; that "insurers agree on a way of verifying impotence"; that "insurers address charges they are hindering patients seeking Viagra with 'unnecessary requirements'"; how "covering Viagra will affect insurance rates" and "[h]ow many pills will be covered, and for how long." The state inquiry was sparked by a Daily News report that "some of the state's biggest insurers won't pay" for the impotency drug (Walker/Siemaszko, 4/29).
The Coverage Debate
Today's New York Times looks at the debate among insurers over whether and how to cover Viagra. Cigna Healthcare "announced yesterday that for men to qualify for Viagra coverage until permanent rules are established they must have a 'pre-existing documented condition of organic impotence, which is currently being treated by other medical means.'" The Times notes that Kaiser Permanente "is expected to introduce a policy similar to Cigna's" this week. However, Kaiser is expected to "reimburse patients for only 50% of the cost of Viagra instead of the traditional 80%" (Morrow, 4/29). The New England edition of today's Wall Street Journal notes that Aetna U.S. Healthcare and Fallon Healthcare Systems "are blocking payment for Viagra" until permanent guidelines are established. A Fallon spokesperson said the company is waiting "to make sure that no problems escaped the notice of the Food and Drug Administration" when it approved the drug last month. The Journal reports that Harvard Pilgrim Health Care's "interim guidelines" for Viagra "suggest a trial of four pills, and if they work, a monthly dose of eight to 10 pills." Tufts Health Plan is "leaning toward adopting the same guidelines," according to a company spokesperson. And Massachusetts' Medicaid program "will cover Viagra with no monthly limits, but prescriptions must be approved by the state in advance," a spokesperson said (Gentry, 4/29).
A Vested Interest
According to the Times, Pfizer "has been pushing insurers to treat Viagra like most other prescription drugs." Pfizer spokesperson Andrew McCormick said, "Our position is that when a doctor is treating a medical condition and he prescribes Viagra, we hope that it would be broadly covered. We also hope that Viagra will be covered irrespective of the cause of the erectile dysfunction, meaning psychological causes as well as medical" (4/29).