SMALL EMPLOYER HEALTH BENEFITS PROGRAM
20 West State Street, 10th Floor
PO Box 325
Trenton, NJ 08625
August 7, 1998
To: SEH Program Member Carriers and Interested Parties
From: Ellen F. DeRosa, Deputy Executive Director
Re: Coverage for Treatment of Sexual Dysfunction
The standard policy forms cover medically necessary and appropriate care and treatment, which includes treatment with prescription drugs. The SEH Board has received a number of inquiries concerning whether the coverage provided under the standard plans includes coverage for Viagra.
While news reports indicate that several carriers have taken the position that Viagra is not covered under plans offered by such carriers, the SEH Board has determined that such a blanket denial of coverage for Viagra in the New Jersey Small Employer market is not supported by the provisions contained in the standard health benefit plans. Further, the SEH Board notes that the standard plans contain no provision which would limit or exclude any medically necessary and appropriate care and treatment of sexual dysfunction.
With the exception of Plan A which does not cover outpatient prescription drugs, the standard plans cover medically necessary and appropriate prescription drugs to treat injury or illness. As would be the case with any treatment or prescription drug, carriers may apply their usual protocols to determine whether a particular prescription drug or treatment is medically necessary and appropriate for the care and treatment of a particular covered person.
The SEH Regulations require carriers to administer the standard health benefit plans in a manner consistent with the provisions of the standard health benefit plans. Any violations with respect to coverage for the treatment of sexual dysfunction, including coverage for Viagra or for any other covered service or supply, will be referred to the Department of Banking and Insurance, Division of Consumer Protection and Enforcement for appropriate action.
Carriers that would like to exclude coverage for Viagra or other services and supplies to treat sexual dysfunction may file an optional benefit rider of decreasing value with the Department of Banking and Insurance pursuant to N.J.S.A. 17B:27A-19.
This Bulletin details the application of the provisions contained in the standard health benefit plans at this time. The SEH Board periodically reviews the coverage provided under the standard health benefit plans and such reviews may result in proposed changes to the provisions contained in the standard health benefits plans.
If you have any questions, feel free to contact me.