Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, June 13, 2009

How Insurance Companies Can Dictate Your Sex Life

If you happen to be a guy suffering from ED (that's erectile dysfunction, not Emergency Department) who requires certain drugs in order to have a satisfactory sexual encounter, you are at the mercy of your insurance company if you expect them to pay for your medication. If the company deigns to pay for it at all, they usually have limits on the number of pills allowed per month. What this means is that your insurance company essentially decrees how often you can have sex.

That's if they cover it at all. The last patient I wrote it for had it "contractually denied" by his company. He wanted me to write a letter of medical necessity so he could appeal it, but if his contract specified that they wouldn't cover it, then nothing I could write would make any difference.

I had occasion last week to prescribe one of these drugs for another patient. I happen to be aware that one of the two behemoth plans in my area pays for 8 pills a month, so I explained to the patient that according to his insurance company, he is allowed to have sex twice a week. I do this so that patients realize it isn't ME who is limiting them to that frequency, but rather their insurance company. I wrote the script and sent the patient on his (soon-to-be) merry way.

Not shockingly, I get a call later in the day from the pharmacy informing me that the drug requires pre-certification. I call the number provided and end up speaking with actual protoplasm somewhat sooner than usual. After being transferred only once, a second piece of protoplasm informs me that the drug in question does not, in fact, appear on the list of forbidden pre-cert-requiring medications.

WTF? Then why did the pharmacy tell me it did?

Answer: Because I wrote for 8 tablets. This company only allows 6 per month. More than that requires a "quantity override" (which will probably be denied contractually). Sorry, dude. You'd have gotten 33% luckier if only your employer had gone with the other company.

I suppose he should be grateful that they approved anything more than a popsicle stick and duct tape.

19 Comments:

At Sat Jun 13, 11:26:00 AM, Blogger Dr. K said...

A popsicle stick and duct tape? *snort* Oh, Dino, I'm mailing you the coffee-on-keyboard invoice.

 
At Sat Jun 13, 04:12:00 PM, Anonymous cynic said...

How do you get your wife to have sex with you 8 times a month ? I just want to answer to that one.

I have tried pre certs, medical necessity claims, you name it.

 
At Sat Jun 13, 04:43:00 PM, Anonymous Anonymous said...

I wonder how, exactly, the insurance companies arrive at the "magic" number? That must be one interesting staff meeting....

 
At Sat Jun 13, 06:57:00 PM, Anonymous Anonymous said...

"What this means is that your insurance company essentially decrees how often you can have sex."

No, what the insurance company is saying is how often you can draw on premiums paid by other enrollees to give yourself a longer hard-on.

In a country where millions of children are not receiving the recommended vaccinations due to failures in the health delivery system, are you really concerned that lifestyle drugs are not completely paid for by insurance companies? I think we have bigger fish to fry!

Thanks,

Robert

 
At Sat Jun 13, 08:19:00 PM, Blogger Lazlo said...

How much do these things cost? I mean, I could search on the internet, but, trust me, that would be a mistake. Is it $20 per tablet? $80? $400? Pretty much whatever it is, even 100% out of pocket it still costs orders of magnitude less than a man is accustomed to paying for sex. Part of the reason thousand-dollar-a-night prostitutes are popular is that, as professionals, they are expected to be more skilled at their trade than the many talented amateurs out there. The other part of the reason is that they are far cheaper than the alternative.

I really don't know, how much of a problem is it for a person to not use insurance for their prescriptions? I know I just picked up a prescription for my son that was $179, of which my insurance paid $2.50, and a while back my wife's doctor prescribed a medication that insurance would only cover 4 pills at a time. The out-of-pocket cost was $70, and the insurance paid the $12 difference. For $3/pill on a $20 pill, I'd just as soon have the doctor write a prescription for 20 of them and pay for them myself rather than drive to the drug store every week.

 
At Sat Jun 13, 09:45:00 PM, Blogger Andy said...

Oh come on! For crying out loud! I think those miserable old people can spare the 10.00 or so per pill. Yes - it might mean that they have to go without cable tv and the shop at home network, but hey - life is not fair.

 
At Sun Jun 14, 07:32:00 AM, Blogger ER's Mom said...

Medicaid pays for condoms here...My script goes : Condoms, Use as Directed, 1 month supply.

I let the pharmacist figure out the number issue. ;) I'm guessing one month supply is however many 'caid will cover.

 
At Sun Jun 14, 08:26:00 AM, Anonymous Married with a Mistress said...

Six pills? Heck, that's a year's worth for many married guys.

 
At Sun Jun 14, 03:23:00 PM, Anonymous Anonymous said...

Considering how many insurance plans do not cover birth control, I really can't bring myself to think the guy is (aha) getting stiffed by his insurer.

Men being able to have sex must be more important medically than women being able to control their own fertility. Or maybe it's just that insurance companies are mostly run by men.

Karen

 
At Sun Jun 14, 10:18:00 PM, Blogger Amanda said...

Our insurance will cover births at 100%, but not female birth control. (You tell me which is cheaper.) It does however cover sterilization. Which is odd in my opinion. Have not had the necessity to look into other such 'Male" pills, but my guess is those are axed too. Although they do pay for a weight loss medication that the pharmacist was amazed only cost my $10 generic co-pay, instead of $60-70.

 
At Mon Jun 15, 12:41:00 PM, Anonymous WhiteCoat said...

Ummm ...
Patients can *suffer from* ED, and patients can still *go to* the ED at the same time.
If a patient signs out of the hospital AMA, you don't have to write "(that's against medical advice, not American Medical Association)" in the chart.
Come on, don't give JCAHO anything else to harass us about.
Now excuse me. I'm going to go take a couple of American Society of Anesthesiologists.

 
At Mon Jun 15, 10:43:00 PM, Blogger The Hatchling said...

We got around this once when I was on family medicine. The patient was depressed that he couldn't function and only was covered I think 4 pills per month. He has previously been on a new (previously pre-certified) antidepressant. He actually got it straightened out himself by calling the company. List cost of his daily antidepressant was well over the $10/little blue bill. All he told the insurance agent was he wanted them to get all his bang for their buck and it was quickly approved.

 
At Tue Jun 16, 03:23:00 AM, OpenID theangrypharmacist said...

Wow, I'd be surprised and/or happy if they only covered 1 tablet, better than nothing.

I think they should bring Caverject back. If you really want that hard-on, you gotta shove a needle in your pee-pee.

 
At Tue Jun 16, 11:29:00 AM, Anonymous Anonymous said...

Okay I NEVER stand up for insurance and yes I am a nurse who works for one BUT here it comes....we as a society can not pay for everything for everyone period the end.Healthcare is a resource and all of us pay for insurance-med coverage -copays etc one way or another we all pay for the resources.Whether it should be 8 tabs or another number someone far smarter than myself decides and YES those meetings are very interesting! but for completely different reasons.Any way bottom line you want something shift your priorities and make the money available to pay for the extra pills you want that are not covered by insurance.Maybe the money the people use on cigs,booze and food that raises the HgA1c might be a start.

 
At Tue Jun 16, 03:50:00 PM, Anonymous Yana Konchin said...

the balance between human being greedy has shifted significantly over the last years. Common people where is the common sense...

 
At Wed Jun 17, 04:27:00 AM, Anonymous Anonymous said...

A lot of women lack insurance coverage for birth control. That is a more compelling story about how insurance companies dictate your sex life than limits on how many ED tables are covered for men. Men can pay for the difference out of pocket, just as women must pay for birth control out of pocket in many cases.

 
At Wed Jun 17, 06:45:00 AM, Anonymous Anonymous said...

Interesting article comparing coverage of ED and birth control.

http://writ.news.findlaw.com/colb/20010103.html

 
At Wed Jun 17, 09:58:00 AM, Anonymous Anonymous said...

An erection is not needed to satisfy one's partner, as the lesbians have known for years...

 
At Wed Jun 17, 03:06:00 PM, Blogger Toni Brayer MD said...

I agree with all the Anons above. With the state of health care in the U.S. and the fact that millions of people can't get even basic health care for themselves or their kids, I think any guy who wants an erection should just pay for it. That little blue pill should be an out- of- pocket expense. Period! Sex has never been cheap. Why should my taxes pay for it?

 

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