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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 98-024 – September 14, 2005
Trustees: Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
The Complainant has been diagnosed by his physician to suffer from erectile dysfunction due to organic causes primarily resulting from multiple medications that the Complainant takes for chronic anxiety and osteoarthritis. In May 2000, the Complainant’s physician prescribed Viagra tablets of 100 mg. for treatment of the Complainant’s erectile dysfunction. Benefits coverage for Viagra has been denied by the Respondent.
Dispute
Is the Respondent required to provide coverage for the prescription drug Viagra?
Positions of the Parties
Position of the Complainant: The Respondent is required to provide coverage for Viagra because the Complainant’s physician prescribed the drug for the Complainant’s treatment of erectile dysfunction.
Position of the Respondent: The Respondent is not required to provide coverage for Viagra because the Complainant’s prescription for Viagra does not result from a treatment or control of an illness or non-occupational accident.
Pertinent Provisions
The Introduction to Article III of the Coal Act Employer Benefit Plan states:
Article III – Benefits
Subject to Article IV, the benefits provided under this Plan are set forth in this Article III. Benefit payments shall not exceed reasonable and customary charges for covered services and supplies. Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. The benefits described in this Article are subject to any requirements implemented pursuant to Article IV. Covered services that are medically necessary will continue to be provided, and accordingly, while benefit payments may be subject to managed care and cost containment rules, this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
Article III. A. (4) (a) of the Coal Act Employer Benefit Plan states in pertinent part:
(4) Prescription Drugs
(a) Benefits Provided
Benefits are provided for insulin and prescription drugs (only those drugs which by Federal or State law require a prescription) dispensed by a licensed pharmacist and prescribed by a (i) physician for treatment or control of an illness or a nonoccupational accident or (ii) licensed dentist for treatment following the performance of those oral surgical services set forth in (3)(e). . . .
Discussion
The Introduction to Article III of the Employer Benefit Plan limits covered services to those that are reasonable and necessary for the diagnosis or treatment of an illness or injury and that are given at the appropriate level of care or are otherwise provided for in the Plan. Article III. A. (4) (a) of the Employer Benefit Plan provides benefits for insulin and prescription drugs (which by Federal or State law require a doctor’s written prescription) dispensed by a licensed pharmacist, and prescribed by a physician for treatment or control of an illness or a non-occupational accident.
Viagra was approved by the Food and Drug Administration (FDA) on March 27, 1998, to treat impotence. It is Funds’ policy to provide coverage for six Viagra tablets per month based on the following guidelines: 1) The patient is of male gender; 2) The patient has documented erectile dysfunction; 3) The patient has chosen this treatment option; 4) The patient is not currently receiving any form of nitrate therapy; 5) If over age 65, the patient is initiating therapy with a 25 mg. dose; 6) If the patient is taking macrolide antibiotics (erythromycin, Biaxin, Zithromax), ketoconazole (Nizoral), itraconazole (Lamisil) or cimetidine (Tagamet), the patient is initiating therapy with a 25 mg. dose.
The Funds’ Medical Director has reviewed this file which included a statement from the Complainant’s physician and an authorization form for Viagra for Funds’ patients. The Medical Director concluded that, based on the information provided, the Complainant meets the Funds’ prior authorization requirements for six Viagra tablets per month.
Opinion of the Trustees
The Respondent is required to provide coverage for the prescription drug Viagra for 6 tablets as prescribed.