Magazine article Drug Topics

Viagra Revisited

Magazine article Drug Topics

Viagra Revisited

Article excerpt

Drug spurs debates on coverage by health plans

Viagra (sildenafil) may be a boon to Pfizer, a godsend for patients, and a seemingly bottomless well of material for stand-up comedians, but it has thrown insurers into a deeper turmoil than the norm and angered some physicians' and women's groups which see a double standard emerging between this drug and oral contraceptives.

Whether to cover sildenafil as a medical necessity (and to what extent) or not to cover it as a lifestyle enhancement is being debated among health plans, pharmacy benefit managers (PBMs), health-care providers, and state and federal Medicaid officials. Even President Clinton has weighed in on the issue.

The overwhelming demand for the product is exemplified by the fact that so many patients are willing to pay now and ask questions later. IMS Health, which provides research and analysis to the pharmaceutical and health-care industries, estimates that the split between cash and third-party payment for sildenafil is nearly 50-50. The normal Rx drug market split is 24% cash versus 76% third-party payment.

While some plans have adopted a waitand-see stance and others are quietly treating sildenafil like any other product, Medical Mutual of Ohio has been very public about creating a short-term, sildenafil-specific policy. Based on guidelines suggested by Merck-Medco Managed Care, its PBM, Medical Mutual will cover 12 pills per month (two more than the 10 recommended for coverage by Pfizer) for males over the age of 18. Merck-Medco spokesman Kevin Colgan said the PBM came to that recommendation based on the self-reported average of patients who participated in clinical trials.

Medical Mutual will be looking at coverage options to replace its shortterm, 12-pill plan over the next three months, seeking counsel from physicians and looking at emerging industry standards. The Cleveland-based insurer has 1.4 million members.

Tim Colligan, director-prescription drug programs for Medical Mutual of Ohio, said one of the goals will be to establish which patients are legitimate candidates for sildenafil therapy and which are simply jumping on the Viagra bandwagon. "Medical Mutual will likely grant approval to cover the drug for males who suffer from impotency resulting from an underlying medical condition, such as diabetes or diseases affecting circulation," he said.

Merck-Medco's Colgan said any coverage decision by Medical Mutual or any other client will be exactly that-the particular company's decision. "They're paying for it. They make those decisions about what to cover and the extent to cover things. Our job is to implement and administer their plan as they've defined it," he explained. "There will be plans that completely exclude it, there will be plans that cover it with no limits, and there will be a whole host of variations in between." Decisions on coverage of any product often come down to economics and philosophy, he said, just like any other employee benefit issue.

Perry Cohen, Pharm.D., a founder of The Pharmacy Group, a health-care consulting firm, agreed that plans and sponsors will need to answer some fundamental questions before setting their standard. "There are big dollars out there to be managed. Do you want to do it at the policy level, from a coverage perspective, or do you want to go inside the HMO and do it at the medical management level? …

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