By Abigail Trafford
Washington Post Staff Writer
Tuesday, May 19, 1998; Page Z06

Unfair! Unfair! cried a physicians group representing women's health. Unfair that many insurance companies are covering prescriptions for the hot new anti-impotence pill for men when many of them don't cover contraceptives. What's more important: that men be able to achieve erections? Or that women manage their fertility?

The charge comes from the American College of Obstetricians and Gynecologists (ACOG), which points out that many traditional health insurance plans do not cover contraceptives, such as the pill or IUD. One study found that nearly 50 percent of these insurers failed to provide contraceptives as part of their basic pharmacy benefit.

Managed care plans, especially health maintenance organizations, do better. More than 90 percent cover contraceptives, according to the American Association of Health Plans.

In the battle of the sexes, the Viagra vs the Pill debate may be a minor skirmish. But it raises important questions about how health plans make decisions on coverage in this era of Better Living Through Medicine.

In general, the medical bean counters evaluate treatments according to guidelines. Medical necessity is the gold standard for determining coverage. Is the treatment necessary to thwart a disease or repair an injury? Does it ease the patient's symptoms? If the answer is yes, the treatment meets the traditional standard of medical necessity.

Thay's why the anti-impotence pill is covered -- in certain circumstances. Health insurers generally will pay for Viagra, but only for men who suffer from "erectile dysfunction" that is caused by an underlying disease such as diabetes. In these cases, impotence is considered a symptom of illness that responds to medical management. Plans tend to limit the covered prescription to six or eight pills a month.

On the other hand, contraceptives are not strictly a medical necessity for most women. Going on the pill is considered a lifestyle choice. Pregnancy is not an illness, but a normal physiological event. Women who take the pill are not sick. They are healthy women who simply don't want to get pregnant. Why should health insurers foot the bill for what is a personal, rather than a medical, decision?

For advocates of broader coverage, the answer comes in the medical impact standard. What is the medical impact of covering -- or not covering -- a certain treatment?

Under this standard, contraceptives get a thumbs-up for coverage. Multiple pregnancies can have profound medical consequences, affecting the health of both the mother and the child. Unplanned pregnancies are linked to higher rates of premature and low-birthweight babies. Repeated pregnancies also increase the risks to the mother.

"There is nothing 'optional' about contraception. It's a medical necessity for women during 30 years of their lifespan," said Luella Klein, ACOG director of women's health issues. "To ignore the health benefits of contraception is to say that the alternative of 12 to 15 pregnancies during a woman's lifetime is medically acceptable."

By contrast, the medical impact of Viagra appears more limited. If men couldn't get coverage and have access to anti-impotence drugs, it wouldn't compromise their overall health or long-term survival. They would still get treated for their underlying disease -- their diabetes or circulatory problems.

But untreated impotence can lead to psychological stress, and for many couples it is devastating.

That's why health plans increasingly consider another standard for evaluating new treatments -- the quality of life standard.

When it comes to improving quality of life, both Viagra and the Pill are extremely important. The two drugs can enhance a person's well-being and enable men and women to function better in their daily lives.

With effective contraceptive methods, couples can "plan" the births of their children and better balance the demands of the workplace and community with the responsibilities of raising a family. And now with a drug for impotence, couples can function better in a sexual relationship.

But the quality of life standard quickly leads to one of the most difficult issues for health plans: What about medicines that enhance the quality of life for people who are not sick? What is the potential of abuse?

"We have an emerging class of drugs being developed for underlying medical conditions that have potential application to enhance the quality of life in people without a medical condition," noted Susan Pisano, director of communications of the American Association of Health Plans, which represents the managed care industry.

The biggest concern is that Viagra will be used as a recreational sex drug among perfectly healthy people. Viagra, like any drug, has side effects -- some of which may emerge with wider use.

Interestingly, when the Pill was introduced, it was described by critics as a promiscuity pill that would allow women to have sex with many men without fear of getting pregnant.

Both drugs involve sexuality and come up against society's ambivalence about sex. Perhaps that explains part of the furor over Viagra and the Pill.