Kaiser Won't Cover Cost Of Viagra / It cites huge price tag -- over $100 million a year

After months of deliberation and intense scrutiny regarding the implications of Viagra mania on healthcare costs, Kaiser Permanente, the largest health maintenance organization (HMO) in the United States, has made the significant decision to announce plans aimed at excluding coverage for Viagra, the well-known medication widely used to treat male impotence. This decision is positioned to stir considerable discourse among stakeholders in healthcare, particularly given the drug's soaring popularity and its perceived need among men facing these challenges.

Furthermore, this HMO's newly established national policy will extend its reach to encompass not only Viagra, but also various other prescription treatments tailored for erectile dysfunction, including emerging formulations like suppositories and tablets that are still in development and pending approval in the marketplace. The ramifications of this policy are extensive, impacting many men who rely on these medications for their well-being and quality of life.

The determination to exclude Viagra from coverage came after a comprehensive national policy review process, which involved a diverse team of healthcare professionals, including physicians, ethicists, and pharmacists. This dedicated group rigorously examined critical issues surrounding the necessity of achieving erections for health and the potential ramifications of recreational usage of erectile dysfunction medications, such as Viagra, which has become synonymous with sexual enhancement.

Since receiving approval from the Food and Drug Administration back in April, an astonishing figure of 2 million prescriptions for Pfizer Inc.'s Viagra have been issued, establishing Viagra as a remarkable and successful pharmaceutical innovation in the medical community. The drug has not only captured the attention of healthcare providers but has also infiltrated popular culture, often referenced in late-night comedy and discussions, highlighting both the curiosity and necessity surrounding it.

Despite its cultural prevalence, the stark financial reality remains that Viagra is not cheap; it carries a wholesale price tag of approximately $7 per pill, while retail prices hover around $9 to $10. In the ultimate assessment, it was found that Kaiser’s decision was profoundly influenced by economic considerations rather than solely medical ones. The HMO estimated that even restricting users to a modest allowance of ten pills per month would result in annual costs surpassing an eye-watering $100 million.

In a revealing contrast, Kaiser managed to dispense only $59 million worth of anti-viral medications last year, encompassing all the necessary protease inhibitors and other high-cost therapies employed in the battle against AIDS.

Dr. Francis Crosson, executive director of the Permanente Federation, Kaiser’s national physician organization, articulated the dilemma: "We certainly could absorb the cost of Viagra and spread it across everyone’s premium, but is that really a fair or responsible approach?" This sentiment encapsulates the broader debate over healthcare coverage and social responsibility.

Kaiser’s policy counteracts the desires of some local decision-makers who had advocated for at least limited coverage options that would be beneficial to certain patients experiencing erectile dysfunction. Other health maintenance organizations have similarly restricted Viagra access, capping coverage at around six pills monthly. In contrast, nearly half of state-run Medicaid programs do provide benefits for Viagra, while standard Medicare's coverage omits any self-administered medications; however, some HMO plans have begun extending Viagra benefits in alignment with commercial insurance offerings.

It’s vital to note that Viagra is currently the sole FDA-approved oral medication affected by this new Kaiser policy. Nevertheless, at least two other potential treatments, which are expected to seek FDA approval in the coming years, will also face exclusion, in addition to the Muse suppository, as noted by Kaiser officials.

SUPPLEMENTAL PLAN NEEDED

As the policy rolls out, it will take full effect during the renewal phase of standard HMO contracts at the beginning of the upcoming year. For employers and other buyers of health plans who wish to pursue Viagra coverage regardless, they will have to consider purchasing an optional supplemental benefit plan. While Kaiser physicians will still have the ability to prescribe Viagra, the cost of the medication will not be covered under the standard $5 co-payment structure.

In Northern California, where Kaiser serves approximately 2.7 million members—equating to one-third of all insured individuals—Viagra has consistently been absent from the list of medications eligible for reimbursement within the HMO framework.

Summarizing the implications of this newly enacted policy, a spokeswoman commented, "Viagra was not a covered medication yesterday, and that will not change tomorrow." This consistent stance underscores Kaiser’s commitment to its financial strategy.

Unsurprisingly, Pfizer expressed disappointment in response to Kaiser’s decision. Spokeswoman Mariann Caprino remarked, "We are truly saddened by this development. The medical necessity of addressing impotence is serious, and it is imperative that we advocate for patient access to treatments." Her statement reflects the broader implications for men dealing with erectile dysfunction.

Exclusion of Viagra, according to industry observers, stands in stark contrast to the established policies allowing coverage for other medications—like antihistamines for seasonal allergies—that enhance the quality of life even when they do not directly address life-threatening diseases.

Many patients and advocates focused on erectile dysfunction sharply criticized Kaiser’s decision, labeling it as misguided and a blunt denial of the recognition that such conditions should be treated as legitimate health issues rather than trivialized. One particularly vocal supporter of Viagra, Santa Rosa resident Eugene Shapiro, aged 63, expressed that the medication not only restored his sexual function but also significantly alleviated his struggles with depression, providing a holistic sense of well-being.

Tom Bruckman, the executive director of the American Foundation for Urologic Disease in Baltimore, responded with shock to the news. He acknowledged that any potential misuse of Viagra has been minimal and unlikely to persist over time, firmly asserting the importance of acknowledging Viagra as a serious medication for a legitimate medical issue.

'STRANGE INCONSISTENCY'

Betsy Imholz, a senior attorney at Consumers Union in San Francisco, pointed out the juxtaposition in Kaiser’s policy, which continues to allow coverage for invasive treatments or surgical interventions addressing erection issues while simultaneously denying coverage for Viagra. In her view, the inconsistency raises questions about the motivations behind the decision-making process. "While I acknowledge the desire to cut costs, it’s perplexing that they choose to cover high-expense surgical options while rejecting a safer, more affordable medication." This dichotomy further highlights the ongoing debate about healthcare access and equity.

Nevertheless, a faction of respected medical professionals stood in support of Kaiser, arguing that it would be inequitable for the vast majority of HMO members to shoulder the financial burden of a few men's sexual pursuits.