The Viagra craze raises some tricky questions- about money. Should health insurance cover sexual satisfaction? If so, how much is enough?

ROBERT POLLYEA JUST GOT A piece of his life back. Until a few years ago, the 66-year-old retired college professor had never complained much about his sex life. But a 1994 prostate operation left him largely impotent, and the penile injections his urologist prescribed were little help. "You have to go to the refrigerator with a syringe, fill it up and inject yourself." he recalls, "all while your wife is there thinking, 'What the hell is going on?' " Everything changed when he started taking Viagra, Pfizer's new potency pill, a few weeks ago. "You use it and have your foreplay." he says. "And when you're ready for intercourse you just do it. It's like when we were first married."

Thousands of older men are now realizing the same dream every day. Urologists are using rubber stamps to keep up with the demand for prescriptions, and Pfizer's stock has soared. But the erection pill's historic takeoff has caught the nation's health insurers off guard. Few of them have decided how to cover the new drug-and as demand explodes, that issue could get large and complicated. Should managed-care plans guarantee their subscribers some sexual pleasure? If so, how much is enough? How should they determine who needs treatment? And how should they pay the tab? Great breakthroughs can have great costs, says Andy Webber of the Consumer Coalition for Quality Health Care. And when health plans cover those costs, we all pay.

No one denies that Viagra can alleviate impotence. Taken an hour before sex, it relaxes the blood vessels feeding the penis, enabling it to respond to erotic stimulation. In clinical studies, 70 to 80 percent of impotent men have gotten good results. But a single pill costs $10-and demand for the drug has been breathtaking. Before Viagra hit the market in early April, erection aids garnered perhaps 20,000 prescriptions a week. Now that relief comes in pill form, American doctors are writing six times that number. If even half of the estimated 30 million U.S. men with erectile difficulties started taking Viagra once a week, the cost would approach $8 billion a year. That's terrific news for Pfizer-even a $1 billion drug is considered a blockbuster-but a big burden for the health-care system.

To control costs, health plans generally cover medical necessities, while eschewing treatments they deem experimental or purely cosmetic. Cancer surgery gets covered; nose jobs don't. And if a drug has more than one use, a health plan may exclude some while allowing others. Most plans cover Merck's Proscar as a treatment for benign prostate enlargement but not as a remedy for baldness. Likewise, your HMO may supply you with Retin-A for acne (a medical condition) but not for wrinkles (a normal sign of age). Viagra is hard to classify one way or the other. Impotence is undeniably a medical disorder, but completely impotent men are not the only ones clamoring for Viagra.

Where should insurers draw the line? Not surprisingly, Pfizer and some patient advocates favor complete coverage. "Managed-care plans cover conditions like arthritis and allergies because they threaten people's quality of life," says Pfizer spokes-woman Mariann Caprino. "That's exactly what we're talking about here." Laurie Flynn, executive director of the National Alliance for the Mentally Ill, takes the same line, saying medical decisions shouldn't be "screened through a financial filter." But covering a drug like Viagra can have as many consequences as rejecting it. "Do you pay for Viagra or do you pay for prenatal care?" asks one managed-care executive. "There's not an unlimited number of dollars here. We get a fixed premium, not one that adjusts because we have Viagra."

Insurers aren't likely to nix the drug altogether; dose for dose, it's actually cheaper than the injections and suppositories they already cover. The challenge is to deal with Viagra's overwhelming popularity. For the time being, Cigna Healthcare is limiting coverage to six pills a month, based on estimates of an average couple's needs. And to qualify for that ration, you have to have 'a pre-existing, documented condition of organic impotence, which is currently being treated by other medical means." Even if they're more expansive, other insurers will likely demand a diagnosis of "erectile dysfunction" before covering a prescription. But "dysfunction" is a relative term. "There's no blood test, no objective parameter," says Dr. Irwin Goldstein. a urologist at the Boston University Medical Center. "It's entirely subjective." In short, anyone who's dissatisfied could qualify as dysfunctional.

At the moment, some men are stretching the definition to absurd lengths. In New York, nightclub kids talk of using Viagra to trump the erection-quashing effects of disco drugs such as Ecstasy and crystal meth. Fortunately, the new pill won't fulfill such fantasies. Handy as it is for treating chronic impotence, there is no evidence that Viagra can boost a healthy man's sexual performance. As thrill seekers learn that lesson, demand may wane a hit. But for millions of men with erectile problems. Viagra seems sure to become a way of life--with or without insurance coverage. "Jack," a 28-year-old Brooklynite, has been partially impotent for six years due to a bike-seat injury. Viagra has restored his sexuality--and he hasn't taken a minute of flak from a health plan because he doesn't have one. "I have a friend who's a pharmacist," he says. "I pay $7 a pill." He considers it a steal.

Drawing the Line

Health plans cover some "quality of life" treatments, but they often impose limits, Some typical policies:

* Accutane: Acne medication. Most HMOs cover it, but special approval is often required. COST: about $5 for a 20-mg capsule.

* Caverject: Injectable impotence drug. Usually covered, but a medical review and prior approval are needed. COST: about $18 for a 10-meg injection kit.

* Clomid: Fertility drug. Not covered unless your employer buys a benefit-rich insurance package; other infertilify treatments may be covered. COST: about $8.50 for a 50-mg tablet.

* Meridia: Diet drug. Not usually covered. If a patient's obesity is life-threatening, doctors can successfully appeal. COST: about $8 for a 10-mg capsule.

* Muse: Penile suppository for impotence. Usually covered, but a medical review and prior approval are required. COST: about $21 for a 250-mcg pellet.

* Propecia: Oral remedy for baldness. Not covered: considered purely cosmetic. COST: about $1.50 for a 1-mg tablet.

* Proscar: Treatment for benign prostate enlargement. Same drug as Propecia, but with a different name and a lower price. Covered for this use. COST: about $2 for a 5-mg tablet.

* Protropin: Recombinant growth hormone for short children. Considered a medical procedure, not a pharmaceutical benefit. Coverage depends on benefits package. COST: $210 for a 5-mg vial.

* Prozac: Antidepressant. Usually covered. COST: about $2.50 for a 20-mg capsule.