KAISER SUED OVER VIAGRA; BURBANK MAN ATTACKS HMO'S ADS.Byline: Ben Sullivan Daily News Staff Writer In what is thought to be the first case of its kind in the nation, a 77-year-old Burbank man has sued his HMO HMO health maintenance organization. HMO n. A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial, for refusing to pay for the anti-impotence drug Noun 1. anti-impotence drug - drug to treat impotence attributable to erectile dysfunction virility drug drug - a substance that is used as a medicine or narcotic Viagra. Attorneys for retired machinery worker Louis Marcil filed suit in Los Angeles Los Angeles (lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. Superior Court late Wednesday to force Kaiser Permanente Kaiser Permanente is an integrated managed care organization, based in Oakland, California, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney R. Garfield. to pay for the popular new medicine and to stop what they say is false advertising by the HMO. Kaiser officials said Thursday that they have not seen the lawsuit, but insist they are not required to cover the drug even if a Kaiser physician has prescribed it. Marcil, a longtime Kaiser member, was left impotent last fall after two years of radiation therapy to kill cancer cells cells once believed to be peculiar to cancers, but now know to be epithelial cells differing in no respect from those found elsewhere in the body, and distinguished only by peculiarity of location and grouping. See also: Cancer in his prostate gland. The World War II and Korean War Korean War, conflict between Communist and non-Communist forces in Korea from June 25, 1950, to July 27, 1953. At the end of World War II, Korea was divided at the 38th parallel into Soviet (North Korean) and U.S. (South Korean) zones of occupation. veteran said that before the treatment he enjoyed an active sex life with his wife of 52 years and that sexual intimacy was an important part of their marriage. ``We'd been having good sex all our lives,'' Marcil said. ``With six months of impotence it was a little rough around the house.'' When the Food and Drug Administration approved Pfizer Inc.'s Viagra in March, Marcil's physician recommended he try the drug. After six months without, ``I told him one pill would be enough'' to get started, Marcil said. According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the suit, Marcil's doctor wrote him a prescription for five Viagra tablets, which Marcil then tried to fill at Kaiser's Panorama City pharmacy. But instead of his customary $7 co-payment for prescription medicines, the pharmacy charged Marcil $50 for the five pills. In the suit, Marcil claims that if the health plan won't pay for Viagra, much of the HMO's marketing material aimed at recruiting senior citizens is misleading. Statements including, ``We will provide all of your health care'' and Kaiser ``physicians have autonomy,'' constitute false and misleading advertising, the suit states. Emotional distress emotional distress n. an increasingly popular basis for a claim of damages in lawsuits for injury due to the negligence or intentional acts of another. Originally damages for emotional distress were only awardable in conjunction with damages for actual physical harm. Marcil is asking that Kaiser change its marketing material and pay for Viagra, and is seeking unspecified compensation for emotional distress. Dr. Les Zendle, associate medical director for Kaiser Permanente in Southern California Southern California, also colloquially known as SoCal, is the southern portion of the U.S. state of California. Centered on the cities of Los Angeles and San Diego, Southern California is home to nearly 24 million people and is the nation's second most populated region, , said that while a physician may prescribe Viagra for a patient, that in itself does not mean the HMO must pay for it. Zendle said Viagra is not on Kaiser's formulary formulary /for·mu·lary/ (for´mu-lar?e) a collection of recipes, formulas, and prescriptions. National Formulary see under N. for·mu·lar·y n. , which is a list of drugs for which the HMO will cover most of the cost. Kaiser will still pay for nonformulary drugs if a physician deems them medically necessary medically necessary Managed care adjective Referring to a covered service or treatment that is absolutely necessary to protect and enhance the health status of a Pt, and could adversely affect the Pt's condition if omitted, in accordance with accepted , but in some cases a doctor will determine a drug is appropriate but not necessary, he said. ``One of the problems from a philosophical point is that with a drug like Viagra there isn't a clear line between medically necessary and non-necessary,'' Zendle said. ``What the physician evidently did not say (in this case) is that it's medically necessary for the patient.'' Zendle said Kaiser has paid for Viagra in several hundred other cases and that still more Kaiser patients pay for the medicine themselves. Frank Darras, an attorney representing Marcil, said the distinction between medically necessary and medically appropriate is not made clear in any Kaiser literature or its member contracts. Unique case Legal experts say because Viagra is the first pill to effectively treat male impotence, the Kaiser case is unique. ``Do you need Viagra? I guess that's the real issue,'' said San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden attorney David Lee, a former chairman of the American Bar Association's committee on health care. ``Health plans have been upheld on this with some frequency, that they are not required to provide everything doctors might prescribe, especially in cases in which the therapy is experimental,'' Lee said. ``But I don't know Don't know (DK, DKed) "Don't know the trade." A Street expression used whenever one party lacks knowledge of a trade or receives conflicting instructions from the other party. if there have ever been situations comparable to Viagra.'' Lee said the case likely will come down to what Kaiser has said in its literature and contracts. Kaiser is being investigated by the California Department of Corporations, which regulates HMOs, for its policy of not including Viagra among its basic drug coverage. Four state legislators have called on the department to pull Kaiser's license unless the HMO begins coverage. Del Konnor, president of the Pharmaceutical Care Management Association, a trade group for managed-care pharmacy benefit managers, said that given the enormous societal interest in Viagra, more lawsuits are likely. ``This is not just a Kaiser Permanente problem,'' Konnor said. ``This is an issue that each plan has to address individually.'' Since Viagra's approval in March, several large health groups including Kaiser, Prudential HealthCare and Humana have said they will not cover the drug, citing alternately its high cost or safety concerns. Others, including Woodland Hills-based WellPoint Health Plans, will pay for a limited number of pills for their members each month. CAPTION(S): Photo Photo: (Color) Louis Marcil, 77, seen here with his wife of 52 years, Venitta, is suing Kaiser Permanente for the HMO's failure to pay for the anti-impotence drug Viagra. Tom Mendoza/Daily News |
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