VigRx Plus Sales Spike Has Insurers in a Dither

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.