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Insurers aim to limit coverage for Viagra

Fearing huge payouts to millions of American men, several large insurers are adopting strict reimbursement policies for Viagra, Pfizer Inc.'s new pill for impotence, requiring proof of a medical cause for the problem and setting limits on the number of pills.

Experts think these preliminary standards, which are being developed amid a frenzy of interest in the new drug, will quickly evolve into a national pattern for Viagra repayment policies. Insurers have been wrestling for weeks with how to cover the drug without paying the claims of men who do not suffer from physical ailments or diseases that are known to cause impotence.

For example, men who are covered by Wellpoint Health Networks in California will not be reimbursed for the prescription unless they have a doctor's written statement that they suffer from erectile dysfunction.

Cigna Healthcare, which covers 15-million people nationwide, announced Tuesday 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."

Once those tough conditions are met, Cigna will pay for only six pills a month. Patients will have to pay the cost out of their own pocket for any more.

Later this week, Kaiser Permanente, one of the nation's largest health maintenance organizations, is expected to introduce a policy similar to Cigna's. But to control its costs even further, Kaiser will reimburse patients for only 50 percent of the cost of Viagra, instead of the traditional 80 percent.

In general, a single dose of Viagra costs about $10 at retail pharmacies, although some are charging considerably more. Men can safely take one dose a day.

"What we're seeing is insurers requiring three things," said Kenneth Abramowitz, a health care analyst in New York. "Insurers will only pay if the impotence has a medical cause. Second, insurers will ask the physician to write a note verifying that the patient is impotent. And then, I expect most insurers to put a limit on the number of pills per month."

While many doctors and patients have been clamoring for health insurers to pay for Viagra prescriptions, the restrictions have not come as a surprise to health care professionals. Viagra is being treated like other impotence drugs, which are subject to the same restrictions, they said.

Since its introduction in late March, Viagra has had one of the most successful debuts in pharmaceutical history. During the week ended April 17 _ the latest statistics available _ 113,000 new prescriptions for Viagra were written, roughly 20,000 a day. Most new drugs average 1,000 to 3,000 new prescriptions a week.

Meanwhile, Pfizer has been pushing insurers to treat Viagra like most other prescription drugs.

"Our position is that when a doctor is treating a medical condition and he prescribes Viagra, we hope that it would be broadly covered," said Andrew McCormick, a Pfizer spokesman. "We also hope that Viagra will be covered irrespective of the cause of the erectile dysfunction, meaning psychological causes as well as medical."

What may be most worrisome to Pfizer is the pattern of coverage that is evolving. Like Kaiser Permanente, Wellpoint will pay only for erectile dysfunction claims of men whose ailment is caused by a physical illness. These include diabetes and high blood pressure but exclude psychological causes, including the use of some antidepressants that can lower sex drive.

"Many of the men whose erectile dysfunction is caused by a medical condition are already being treated," said Robert Seidman, vice president of Blue Cross of California, the California operating unit of Wellpoint. "We cover that, so we wanted to continue that policy. We can also check to make sure the claims are legitimate by looking in the computer to see if the patient is being treated for the medical condition."

Insurers insist that they have little choice but to scale back the reimbursement amount to 50 percent to help prevent widespread insurance fraud. That is one of the few ways, they say, to discourage millions of men who simply want the pill to improve their sexual performance from pressing their doctors to lie about the reasons for demanding Viagra.

"It's not at all surprising that insurers will only pay for half the Viagra prescription," said Abramowitz, the analyst. "And remember, if someone wants more Viagra, he can pay for it himself."

But where did the insurers get the idea of limiting Viagra's reimbursements to six pills a month? Pfizer executives say they are baffled by the ceiling. In its clinical trials, Pfizer gave men eight pills a month, a number gleaned from the 1994 study, "Sex in America." In the study, researchers concluded that 41 percent of married couples had sex twice a week.

Most American men, at the recommendation of Pfizer, are receiving monthly prescriptions of 10 pills a month, essentially to give men a couple of extra pills beyond the norm.

For their part, insurers said they sought to set reasonable limits on how much they would pay for Viagra. Wellpoint officials, Seidman said, interviewed urologists and read the general medical literature before deciding to reimburse no more than six Viagra doses a month.

"We thought long about it," Seidman said. "It didn't make sense to do something like pay for only two, and paying for 30 pills a month does not make financial sense."

But even though insurers may be treating Viagra as a potential budget buster, it may turn out to be a lot less costly for them than paying for some of the earlier, more intrusive, treatments. Many insurers already cover Caverject, an injectable product made by Pharmacia & Upjohn, and Muse, a medication sold by Vivus, which both cost about $17 per dose.

Until Viagra came along, about 2-million men a year were being regularly treated for impotence. As long as most of these men, who should have little trouble proving their need for the drug, are not allowed to seek repayment for lots of extra doses, many insurers may well come out ahead.

Neil Sweig, a pharmaceuticals analyst, has another worry about the treatment of Viagra insurance claims. "Part of everyone's projections for sales are based on renewal rates," Sweig said. "That's a problem if people try Viagra and decide they can't afford it again."

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