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Viagra Spurs New Questions About HMO Drug Coverage

June 08, 1998|BOB ROSENBLATT

HMOs and health insurance companies, not exactly basking in the sunlight of public approval these days, have a new worry: Should they pay for Viagra?

The answer is yes, no and maybe, as the demand for the blue pill that enables impotent men to have erections makes it among the fastest-selling new drugs. Decisions on insurance coverage drift into the murky area where medicine, physical health, emotional satisfaction, sexual desire and morality collide.

If you are a man covered by Blue Cross of California, your health insurance will pay for six pills a month, provided you have a condition requiring the medication. For example, a man who is impotent because of diabetes, prostate problems, the side effects of blood pressure medication or some other condition can get a prescription. Why six guaranteed erections a month? That's what was recommended by outside expert advisors. And who might these be? Psychologists, psychiatrists and doctors at leading teaching hospitals, according to Blue Cross.

Blue Shield of California, evidently using some of the same experts, also will approve six pills a month, prescribed and dispensed only on the grounds of medical necessity.

However, the management at PacifiCare does not yet recognize Viagra as an acceptable response to impotence. The medical directors for the health plan will meet at a national benefits committee this month to define medical necessity for Viagra and to write guidelines for physicians.

So far, all the HMOs and health insurers covering Viagra are saying a man has to have a specific medical condition to get the pill. But what if he has no identifiable organic problem, yet gets a referral from a psychiatrist or psychologist for Viagra on the grounds that his inexplicable impotence depresses him and harms his emotional health?

The prospect of spending lots of money on the magical blue pills without a concrete medical diagnosis makes medical plan managers quite nervous. "We don't want to prescribe it just because a man is horny," said an official of one health plan, who understandably asked not to be identified.

Then, for an otherwise healthy man, is Viagra a medical necessity or a "lifestyle choice"? After all, health insurance plans won't cover cosmetic surgery for people who want eye tucks and face lifts. What about an unhappy man, now 50, who simply wants to restore the erectile performance he enjoyed in the bygone days of the Woodstock festival?

If men are getting access to Viagra, courtesy of their health plans, women should have their contraceptives fully paid for, says the Planned Parenthood Federation of America.

"With Viagra receiving almost instant coverage under many health insurance plans, there is no longer any excuse for insurers to exclude coverage for contraceptives," said Gloria Feldt, president of Planned Parenthood. "Viagra means more sex. More sex means more need for effective contraception."

Coverage varies considerably. More than 80% of HMOs include birth control pills and diaphragms as part of their regular coverage, compared with less than 40% of regular fee-for-service health plans, according to a recent survey by the Alan Guttmacher Institute. But coverage for IUDs and Norplant is much more unusual, with these contraceptive methods paid for by less than 50% of HMOs, and less than 30% of the fee-for-service plans.

About 70% of health plans will pay for abortions, and more than 80% routinely cover sterilizations and vasectomies, the survey indicated.

Infertility is another matter. Health plans will diagnose the causes of the problem. But what they do about it is quite different from plan to plan. Most will cover the drug clonimid, a treatment for infertility. But hardly any--only 17%--will pay for in vitro fertilization.

The arguments here focus on costs. Payment for in vitro fertilization raises the cost of health insurance higher than most corporate employers are willing to pay, health plan managers argue.

In the end, the insurance companies and HMOs are the middlemen moving dollars between payers and medical providers, reflecting society's demand for care and its willingness to pay.

What kind of damage does a woman suffer to her emotional health because of infertility? And is that a condition that all health plans should deal with? How does a man's despair because of impotence compare with a woman's anguish over infertility? These are painful questions, and will become louder and louder with the aging of the baby boomers, the 76 million Americans born in the years from 1946 to 1965. In the end, their voices will determine what gets paid for by insurance, and how much must remain the financial burden of the individual.


And now, switching from the cosmic issues to the concrete problems of our readers.


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