2002-07-01 17:00:15 -0400
By Karen Pallarito
NEW YORK (Reuters Health)
California regulators can't force Kaiser Foundation Health Plan Inc. to pay for Viagra, a state appeals court has ruled.
Upholding a trial court ruling, the 3rd District Court of Appeals in Sacramento agreed that the California Department of Managed Care overstepped its authority by ordering Kaiser to maintain coverage of prescription drugs, like Viagra, for treating sexual dysfunction.
The state legislature never intended to mandate coverage of all drugs for every medical condition, the court reasoned. Otherwise, there would be no need for separate provisions that specifically require health plans to cover drugs for pain medication for the terminally ill, contraceptives for women and insulin for diabetics, it said.
The case sets the stage for renewed legislative wrangling over what drugs a health plan must cover, be they so-called "lifestyle" drugs, like Viagra, intended to enhance the quality of life of otherwise healthy individuals, or medications for treating serious medical conditions.
Tony Barrueta, Kaiser's senior counsel, said he believes there's general agreement among California health plans that drug benefits should be comprehensive. He said the court ruling establishes "that plans have flexibility in determining what their drug benefits can be composed of."
But Daniel Zingale, director of the California Department of Managed Care, which filed the appeal, said the decision gives HMOs the right to deny access to medications for serious conditions, including treatments for heart and cancer patients.
"The state was never in this fight for Viagra or any lifestyle drug in particular," he explained. "We're fighting for patient access to lifesaving drugs and access to life-sustaining medications."
Zingale said the department has asked the legislature to act quickly to ensure that patients are guaranteed some minimum level of security in terms of the scope of drug coverage health plans provide. It is seeking "general guidance" on the drugs that should be covered, rather than a list of specific medications.
Kaiser's fight to exclude coverage of prescription medications to treat sexual dysfunction began in 1998, in anticipation of Pfizer Inc.'s introduction that year of Viagra (sildenafil citrate)--the first pill for the treatment of male impotence.
Because regulators denied the exclusion, California is the only state where Kaiser pays for Viagra. Its contracts provide for eight doses a month at 50% coverage, Barrueta said.
In the wake of the ruling, officials of the Oakland, California-based HMO, a unit of Kaiser Permanente, have yet to revisit whether to drop Viagra coverage in the state. "To some extent it depends on what the employers who purchase coverage want to do," Barrueta noted. As part of the analysis, the HMO will consider the cost implications, he added.
Barrueta frames the legislative battle ahead in terms of relatively
low- and relatively high-value classes of drugs. Paying for low-value drugs,
he said, "could potentially crowd out much more important drug coverage."
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