With one Connecticut physician calling it "the biggest thing since the Beatles," Viagra, Pfizer's popular pill for impotence, has burst onto the scene like few others. Its popularity seems to have caught insurers off guard as they scramble to develop a yardstick for coverage.

According to IMS America, which tracks pharmaceutical trends, physicians were writing close to 300,000 Viagra prescriptions a week in mid-May.

The phenomenon has forced health plans to deal with such questions as, "How much sex is enough?" No clear consensus about how many pills to cover has emerged. The old standbys of covering 30- or 90-day supplies aren't easily calculated for drugs that are taken as desired.

Though dozens of plans announced they will pay for the drug, levels of coverage differ. Some cover six pills a month; some, eight. Wellpoint says it will pay for Viagra only with a physician's statement that a patient suffers from erectile dysfunction. Cigna says its coverage applies only to men with preexisting, documented diagnoses of impotence who have been treated by other means.

That could keep more than a few closet doors shut. Viagra has not only run away with the market for sexual disorder treatments — only 5 percent of such prescriptions are for any other product — but it has expanded it, too. The market has grown more than 500 percent since Viagra's early April debut.

Still, many insurers seem to be sitting on the sidelines while the other guy figures an appropriate coverage level. IMS estimates that 53 percent of Viagra prescriptions are paid by cash.

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There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.