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Get Your Claim Paid: Lifestyle Coverage Disputes

In July 1998, 77-year-old Mouis Marcil filed a lawsuit against Kaiser Permanente for refusing to cover Viagra, the impotence drug introduced in March 1998 by Pfizer.

The lawsuit was filed in Los Angeles Superior Court on behalf of Marcil, a retired sales manager living in Burbank, Calif., who is a client of Kaiser's Senior Advantage program. Marcil claims to have become impotent in 1996 due to radiation treatment for prostate cancer. Marcil said he received a prescription for Viagra in April from his Kaiser urologist but was told the HMO would not cover the $10-per-pill cost.

Kaiser Permanente, based in Oakland, California, excluded Viagra from its regular benefits contracts. The HMO, however, said it would pay for the drug if supplemental benefits coverage was purchased.

Kaiser's main concern was that covering the drug would raise policyholder premiums. It estimated that full coverage of Viagra would cost at least $100 million annually.

The suit charged Kaiser with fraudulent and unfair business practices and said that Kaiser's contract provides for coverage for prescription drugs without excluding any particular class of drug except those used solely for cosmetic purposes.

According to Marcil's lawyer, Frank N. Darras, Kaiser's marketing materials for Senior Advantage claim it will cover customers' prescription needs for at least 100 days. "Kaiser promised to cover all their health care needs," said Darras. "When it came time to pay for Viagra, they would not honor the words of their contract."

Kaiser has been paying for Viagra coverage for a small number of patients for whom a doctor has deemed it a medical necessity, said spokesman Jim Anderson. He would not quantify whether the HMO is paying for all, most or some of those for whom it is deemed necessary and did not speak specifically about the case.

Marcil, who had been married 52 years, said he had been purchasing the drug himself and finds it effective. He was suing for the $50 he had spent on the five Viagra pills he'd purchased so far and for emotional distress. No dollar figure had been set for the emotional distress element of the suit, as per California law.

Darras said the suit could take about a year to settle but could be resolved as early as the end of summer. In another case involving prescription drugs, NYLCare Health Plans of the Mid-Atlantic Inc. was accused of non-compliance with a law that entitles certain patients to a 90-day supply of prescription medication.

In 1997, the Maryland Insurance Administration brought a sanction against the company after it received complaints between April and September that NYLCare denied members covered by its prescription drug rider the 90-day supply, according to the order signed by Maryland Insurance Commissioner Steven Larsen.

Under the Maryland law, health plan members who require maintenance medication for chronic conditions are entitled to a 90-day supply each time a prescription is refilled. The 90-day supply cannot be limited to purchase through a mail-order program.

NYLCare contended that it had complied with the law by making 90-day supplies available exclusively through its mail-order service. The HMO said administrative problems prevented it from providing wider access to members whose plans were effective prior to July 1998.

It didn't prevail.

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