Maryland insurers in general are paying for prescriptions for Viagra, the hot new $10-a-pill treatment for male impotence.
And the demand has been high. "It's like when we invented vasectomies," said Dr. Stephen Cohen, chief of urology at Sinai Hospital. He said his office is getting 30 phone calls a day inquiring about Viagra.
Michael Podburkski, director of pharmacy for Rite Aid Corp., said he started getting questions about the availability of the drug even before it was approved by the Food and Drug Administration. "Most insurance is covering it, and patients are willingly paying cash if it's not covered," he said.
But insurers are nervous about a product for which "the potential demand is unlimited," said Alan Lyles, assistant professor of health policy and management at Johns Hopkins School of Public Health.
Most say while they are currently paying for Viagra, their coverage is under review. And, in the interim, there are exceptions and conditions to the coverage:
Not all employers' health plans include coverage for sexual dysfunction. So, for example, Blue Cross Blue Shield of Maryland pays for Viagra for state employees, but not federal employees, says Jeffery W. Valentine, director of corporate communications.
Some employers buy health plans that don't cover prescriptions at all, and traditional Medicare also does not cover prescriptions. (Many Medicare HMO plans include some prescription benefit.) This is fairly rare, however; the Employee Benefits Research Institute in Washington said 96 percent of workers participating in health plans get prescription drug benefits.
Insurers differ in the amount of documentation they require from physicians. In some cases, this, too, stems from differences in policies. For example, the standard benefit package in the state's small group market, which covers 420,000 Marylanders, excludes "sexual dysfunction which is not related to organic disease," so insurers may ask doctors about the cause of impotence before approving claims.
ZTC That still covers most impotent men, according to Dr. Melvin Duckett, president of Maryland Urology Group, who specializes in treating sexual dysfunction. The National Institutes of Health concluded that 10 percent of impotence stems from psychological problems, with the rest from organic causes, he ,, said.
Even where insurers are paying for the pills, there's a question of how many pills. Most policies cover a one-month or three-month supply of any prescription, but Viagra doesn't have a set daily dose -- it is to be taken about an hour before intercourse.
"So now the insurance companies are in the business of deciding how often you should have intercourse in a month," said Cohen.
Blue Cross covers up to 12 pills a month, Valentine said. Richard Reitz, director of pharmacy for NYLCare Health Plans of the Mid-Atlantic, approves six tablets a month, based on dosages of other impotence treatments, such as injections.
Blue Cross insures about 1.4 million Marylanders. NYLCare has about 500,000 subscribers in Maryland,
An economic judgment
"It's not so much a value judgment by the plans as an economic one," said Lyles, who studies how managed care deals with pharmaceuticals.
Pharmacy costs have increased from 8 percent to 13 percent of health insurance claims, said Myron Holubiak, general manager of the consulting group for IMS America, a New Jersey firm that tracks drug marketing and other health data.
Consequently, he said, they are watching all prescription costs closely, and most insurers were likely to end up with some restrictions designed to minimize "recreational use" of Viagra.
With expensive drugs, insurers often require prior approval before paying for a prescription, Lyles said.
That's how NYLCare is dealing with Viagra, according to Reitz. It will pay only if a prescription comes from a urologist, and only if the urologist faxes documentation of a "specific organic cause" for the impotence.
Sales rise quickly
Mid Atlantic Medical Services, Inc., a Rockville insurer with 326,000 Marylanders in its two HMOs, M.D.IPA and Optimum Choice, said it is asking physicians to document "medical necessity" when requesting insurance coverage for Viagra.
In the few weeks Viagra has been on the market, sales have increased rapidly -- going from 36,700 prescriptions the week of April 10 to 115,000 the week of April 17, according to IMS America data.
Pub Date: 5/05/98