Despite the recent news that Medicare will not exclude erectile dysfunction drugs from coverage limitations, health plans responded with a ho and a hum. That's because when sildenafil (Viagra) arrived on the scene in 1998, health plans and employer groups got together and hashed out a benefit package that took into account the risks, benefits, and cost.
David Clark, RPh, MBA, vice president for pharmacy benefit management at the Regence Group, says, "It's not something we're looking at to include in our commercial benefits. I think that those plans that cover it today will continue providing coverage. But those that have set it up as an exclusion, as in our situation — I don't see a need for a change."
Will this open the door for other so-called lifestyle drugs to gain coverage? "Probably not for this therapeutic category, but for other lifestyle drugs that are not so 'lifestyle oriented.' For example, weight control drugs that may receive an indication for diabetes will have a bigger effect on formulary structure," says Clark.
Historical data from MediMedia's Formulary Compass, a continuously updated compilation of formulary information, shows sildenafil with the most coverage by health plans (without prior authorization) as well as tier 2 position in more than 24 percent of plans surveyed in 2005.
Erectile drug coverage and formulary position
Source: MediMedia's Formulary Compass