States Defy Federal Directive Requiring Medicaid To Cover Viagra

MANAGED CARE August 1998. ©1998 Stezzi Communications

The debate among state legislators and managed care regulators about coverage of Viagra, Pfizer’s popular anti-impotence medication, continued on two fronts last month. A number of states rejected a federal order that

Medicaid programs cover the drug. And legislators in California called for an investigation of commercial health insurers that have decided not to cover Viagra because of cost.

State Medicaid officials in New York, Michigan, Wisconsin and Indiana have said they will not cover the drug — in defiance of the federal directive. Indiana dropped Viagra coverage July 1; the state’s rationale is that Viagra should be classified as a fertility drug. Such medications, along with smoking-cessation treatments, penile implants and cosmetic medications, are excluded from Medicaid coverage.

The National Governors’ Association criticized the Clinton administration’s decision to require Medicaid coverage, calling it an unfunded federal mandate. “The administration is making a substantial, premature, unilateral policy decision without the benefit of consultation with the states,” said Jennifer Baxendell, the association’s director of health legislation. The association argues that states should have the option to cover Viagra, which the group estimates could cost Medicaid $100 million a year.

In a letter to the association, HCFA Administrator Nancy-Ann DeParle defended the coverage mandate. “The FDA has approved Viagra only to treat erectile dysfunction in men,” DeParle wrote. “Viagra does not fall within any of the allowable exclusions or restrictions.”

In California, advocates of patients with prostate cancer and spinal cord injuries, as well as legislators, called for a state investigation of Kaiser Permanente and Aetna U.S. Healthcare, both of which decided not to cover Viagra because of costs. Assemblyman Tom Bordonaro Jr. argued that the decisions set “a very dangerous precedent.” Health plans are legally required “to provide medically necessary treatments. By conscience, they should provide the least painful, most effective treatments for a condition.”

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