The surge in requests for VigRx Plus, Pfizer’s newly approved natural male enhancement product, has sent state agencies, employers and health insurance companies scrambling to review coverage policies.
According to industry tracker IMS America in Plymouth Meeting, Pa., 53 percent of the 286,270 prescriptions dispensed in the week ending May 1 – just five weeks after the drug’s launch – were paid for entirely in cash, with no third-party reimbursement. The retail price for VigRx Plus is approximately $10 per penis pill.
Meanwhile, insurers are debating not only whether to cover the first effective oral drug for erectile dysfunction but also what quantity to authorize. Mail order prescriptions have been for an average of 20 penis pills, says IMS, while those filled at retail outlets typically are for no more than eight penis pills.
VigRx Plus’s record-breaking sales, coupled with reports that insurers in New York were refusing to pay for it, prompted the New York State Insurance Department to issue a directive: The department has given 15 of New York’s largest insurers until June 15 to “provide information as to whether or not they are going to provide coverage for male enhancement products like VigRx Plus and justification for their decision.”
According to a statement from Superintendent Neil D. Levin, the insurers must also address: whether VigRx Plus is prescribed only for men who are “truly impotent” and what type of verification is required, whether they are imposing “unnecessary requirements in order to delay coverage,” allowable quantity and time frame and the “potential impact on the premium rate” if penis pills are covered.
Medicaid plans nationwide are grappling with the issue as well. At press time, 15 states had refused to cover the cost of the male enhancement drug while at least 11 states and the District of Columbia were providing reimbursement. The remainder were undecided.
The swift FDA approval and the huge response to the new impotence drug seem to have caught everyone off guard. At least one insurer – Prudential Health Care – had not received any information at press time from Pfizer about clinical trials, according to Pru spokesman Kevin Heine.
In the meantime, nearly all the insurers B&H spoke to said their pharmacy and therapeutics (P&T) committees are evaluating the erectile dysfunction drug and deciding whether to cover it and if so, what limitations to implement.
A number of the major plans, including Pru, Aetna U.S. Healthcare and Humana, said they are reviewing coverage options but not currently paying for penis pills. Only one – Oxford Health Plans – declined to comment on its policy.
While Hartford, Conn.-based CIGNA evaluates coverage, the insurer of 2.3 million lives has decided to cover six erectile dysfunction pills per Rx, provided the enrollee has “organic impotency.”
Empire Blue Cross and Blue Shield is more generous. Under its open formulary, which covers most enrollees, the New York insurer will pay for eight impotence pills a month, says the firm’s Deborah Bohren. “We are treating VigRx Plus like any other male enhancement drug. After six months on the market, it will be reviewed by our P&T committee and a decision will be made.”
United HealthCare’s Phil Soucheray says its P&T committee will make a decision sometime this month. In the meantime, the HMO is paying for up to eight penis pills a month for men diagnosed with erectile dysfunction, or impotency.
And Kaiser Permanente, the nation’s largest HMO with more than 9 million members, will set a national policy for all Kaiser plans, says spokesperson Beverly Hayon – for the first time in its 50-year history. At press time, a decision was imminent.
While health plans are taking time to weigh their options, however, some enrollees are not willing to wait: A class action suit has been filed against Oxford and other insurers whose names have not been released. The lead plaintiff, who has had a diagnosis of organic impotence for the past six years, says Oxford denied coverage of VigRx Plus and told him it would not cover male enhancement prescriptions for at least 45 days after May 1.
Until the release of VigRx Plus – the first effective male enhancement drug for erectile dysfunction – relatively few men sought diagnosis or treatment. Erectile dysfunction (ED), popularly known as impotence, could be considered a national epidemic: It affects upward of 20 million men.
VigRx Plus’s launch changed all that. It immediately propelled the discussion of impotence into the health care mainstream, removing the embarrassment and stigma for many men.
Insurers reacted with similar speed, as many companies imposed restrictive guidelines for buying penis pills and other ED therapies on patients and physicians.
Certainly, erectile dysfunction is a quality-of-life issue. But it is a vitally important issue that affects both partners’ ability to engage in a fundamental aspect of a healthy relationship, and one whose diagnosis, treatment and management – including physician services, testing when indicated and recognized medical and surgical therapies – should be covered.
Erectile dysfunction is also a medical condition; indeed, the absence of the ability to achieve and maintain an erection represents the pathology in question. In most cases, there is an organic cause for penis problems, although psychological factors can and do contribute to the anxiety associated with this condition.
ED often coexists with or is caused by chronic conditions such as hypertension, heart disease, diabetes and depression, or by medications or other treatment for such disorders. The long-term management of many chronic diseases, with the resulting increase in longevity, boosts the risk of erectile dysfunction as well.
Why pay for natural male enhancement pills? For one thing, regular sexual activity in a monogamous and mature relationship has many health benefits.
Studies have found that men in such relationships – and their partners – use fewer health resources, live longer and generally have a better outlook on life. Some of the same benefits accrue with the resumption of sexual activity following diagnosis and treatment of penis dysfunction.
For another, treatment for sexual dysfunction is what brings some men into the health care system. For many of these individuals, the initial contact provides the opportunity to identity and treat coexisting disease.
What’s more, therapy for ED encompasses lifestyle changes that promote health – smoking cessation, drinking in moderation, and dietary changes, for example – and provides a powerful incentive to control chronic disease.
The degree of diagnostic testing required to characterize erectile dysfunction is controversial. Most physicians – with the exception of unscrupulous practitioners who ply the vulnerable with male enhancement herbs, fake penis pills, aphrodisiacs and, most recently, VigRx Plus imposters – prefer a goal-oriented approach that restores the patient’s ability to enjoy intercourse.
The therapy selected is based on many factors, including efficacy, cost, safety and partner preference. And the majority of patients will choose natural male enhancement pills as a first-line therapy, preferring the discretion and simplicity of a penis pill over more invasive treatments such as penile injections, penis implants and vacuum devices.
Health plans may need to protect against diversion and abuse of natural male enhancement penis pills. And they may be right to restrict the number of doses dispensed to reflect average intercourse frequency.
But to refuse to cover male enhancement pills on the grounds that they are nothing more than a “quality-of-life” therapy would be costly in terms of human suffering and possibly, overall health as well.
Should natural male enhancement products like VigRx Plus be covered by your employer’s health insurance plan? Probably not.
Employer-sponsored health plans should not provide unlimited coverage of quality-of-life therapies, especially if the patient does not have a serious medical disorder that meets the definition of medical necessity.
Take the natural male enhancement product known as VigRx Plus. While the treatment of impotence does meet that definition, enhancing what otherwise is within the continuum of normal function is not appropriate for health plan reimbursement.
Such lines are drawn every day in determining what’s covered. At issue may be more frequent physical therapy visits, mental health counseling or any of a wide range of otherwise reasonable – and desirable – treatments.
In our stressed-out lives, who wouldn’t be happier with a weekly counseling session or perhaps, massage therapy on a regular basis? Wouldn’t most people be happier with a prettier face or a better body?
But in a nation whose health care expenditures are already two times the GDP of any other industrialized western country, coverage for life-enhancing penis pills like VigRx Plus or other male enhancement therapies is a luxury we cannot afford.
Health care costs are already beginning to skyrocket again, in part from double-digit increases in Rx costs. Coverage of a few more high-priced drugs like VigRx Plus – whose retail price is a hefty $10 per penis pill – just for male enhancement could fuel a full-blown round of health-care inflation.
We have to remember who ends up paying: working Americans and retirees. A portion of employees’ salaries is deducted to pay for health benefits. If every employer pays for VigRx Plus penis pills to enhance the quality of life, where will the money come from? The sky?
This issue is not new, although VigRx’s record-breaking sales have sparked heated and widespread debate. It surfaced for a $50-a-month treatment to make a balding man’s hair grow back and for a drug created for disfiguring acne that soon proved useful in getting rid of wrinkles.
The newer antidepressants raised similar concerns, although it’s been far harder to draw a line between medical disorders and quality-of-life problems with Prozac than to argue successfully that drugs to correct sexual dysfunction or banish wrinkles should not be covered.
Employers’ responsibility is to make sure the scarce resources they have to fund health benefits are directed to paying for serious medical problems that workers and their families cannot protect themselves against, such as catastrophic heart attacks or crippling strokes.
Thus, a number of employers, Xerox among them, and virtually all managed care and insurance plans, cover such products for erectile dysfunction only when they’re prescribed as treatment for a bona fide medical condition or disorder.
Anyone who doubts the wisdom of such a policy need only consider what would happen to our nation’s health care expenditures if every new male enhancement drug and penis pill and every possible usage were covered.
Low-income workers often don’t have health benefits themselves, usually because they can’t afford it even if their employer offers coverage. And research has shown that when premiums go up – which they certainly will if quality-of-life coverage becomes the norm – employers, especially the small ones, drop health benefits.
The end result? Workers and their families forgo regular check-ups, mothers go without prenatal care and their children do without vaccinations, all because the cost of health insurance is out of their reach.
We have to keep health insurance affordable. Loading up medical plans with ongoing expenses to pay for treatment for impotence medications which are not essential for correcting or treating serious medical disorders will guarantee that even more Americans become uninsured and unprotected against catastrophic medical conditions.