Posted by: notdeaddinosaur | 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.

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Responses

  1. I’ve been limited by my insurance to 6 per month. Considering that I gave an entire career to the US military with the promise of 100 percent healthcare, it seems odd that this practice is even allowed. If they remove the limit & raise the co-pay it all comes out even, except that the patient (me, in this case) gets to have his blood pressure normalized and still have sex. I can’t believe the pharmaceutical companies are putting up with this. It seems even more rediculous when one considers that, with cialis, 4 more, a total of 10, covers an entire month satisfactorily. Why 6? Why not 10. My co-pay is 25 bucks for 6. I’d gladly pay 50 for the full month. . .but I’m not given the option.


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