But none of the five drugs covered for erectile dysfunction ranks among Utah Medicaid's most costly or widely prescribed.

Instead, the state's pharmacy bills are bumped up by antidepressants and antipsychotics used to treat the chronically depressed and mentally ill; pain and swelling relievers for the elderly; and drugs to regulate heartburn, high blood pressure and cholesterol.

Efforts to contain these costs are less politically expedient than proposals to restrict Viagra, but far more critical, say medical experts and advocates for the poor and elderly. They're also more complicated.

"We need to look at ways to bring costs down, but not restrict access, which seems to have been the focus of a lot of recent reform: reduce, reduce, reduce," said Laura Polacheck, associate director of Utah's AARP. "Many of these drugs are crucial to maintaining a person's quality of life and keeping hospitalization costs down."

Prescription drugs aren't Medicaid's biggest expense, but they constitute the fastest-growing. In fiscal year 2004, Utah Medicaid spent slightly more than $183 million filling 3.3 million prescriptions for 194,127 Utahns.

State Health Department officials say there is no single factor driving costs. The average price per drug rose 1.4 percent to $56. Drug use also is up, with 400,000 more prescriptions written in 2004 than 2003.

But Duane Parke, who oversees Medicaid pharmacy claims, says intense direct-to-consumer marketing by drug makers and the swelling Medicaid rolls also are to blame.

"There is more demand for the latest and greatest drug on the market. We also have an aging population, so as baby boomers start using more drugs, that adds to it," said Parke.

Health officials already aggressively work to find savings for the medical assistance program, and more proposals are on the horizon.

Following national reform, many elderly enrollees will soon have their medications picked up by Medicare, which is administered and paid for by the federal government. Currently, 30 percent to 45 percent of Utah's Medicaid drug costs are attributable to these so-called "dual eligibles."

The elderly make up many of the chronically ill who use multiple drugs and painkillers, ranked No. 1 for prescription volume, says Joanne LaFleur, a pharmacist at the University of Utah.

"But we're having a hard time getting a handle on whether the switch [to Medicare] will pay off," she said. "Utah won't have to pay for the meds, but we'll lose federal matching funds."

LaFleur participates in another program, estimated to have saved the state $3.8 million last year.

She and other U. pharmacists screen Medicaid pharmacy claims looking for doses that are too high or too low, similar drugs prescribed for a patient by more than one doctor, and forgotten refills.

A chief focus for the review team are mental health claims, which account for a third of all Medicaid drug costs. Antidepressants and antipsychotics for the chronically depressed and people suffering from schitzophrenia or bipolar disorder rank among the most expensive and commonly used.

Although overall treatment for mental health is on the rise, providers wrote 5 percent fewer mental health prescriptions for Medicaid patients reviewed by LaFleur's team.

Sherri Wittwer, the new director of Utah's chapter of the National Alliance for the Mentally Ill, applauds the program for reducing waste and improving patients' quality of care. But she cautions against imposing a seven-drug-per-patient ceiling, as other states have done.

"Treating mental illness is always wiser for the individual and society than leaving it untreated," Wittwer said. "It can cost families greater stress, lead to unemployment and unnecessary disability, homelessness, incarceration and other physical ailments."

LaFleur says the same logic applies to other patients who use a higher number of drugs, such as diabetics.

Someone with diabetes that hasn't progressed far enough to require insulin injections could be on one drug to reduce his body's production of glucose; one to improve his response to insulin; one to boost his insulin production; and could need lancets, alcohol swabs and diagnostic strips for testing his blood-sugar levels.

Such a patient probably also could be taking two to three drugs for high blood pressure and cholesterol, which tend to go hand-in-hand with diabetes.

"There you have a patient easily over the seven-drug threshold," said LaFleur, noting that diabetes is becoming more prevalent.

But the good news, she says, is that treating diabetes with drugs is far less costly than hospitalization, required when diabetics slip into end-stage renal disease, have a heart attack or stroke, or need an amputation.

LaFleur joins advocates for the poor in backing another money-saving plan - a preferred-drug list to encourage the use of less expensive drugs. Health officials also have recommended joining a purchasing pool that would allow Utah to negotiate with drug companies for steeper discounts.

Together these measures are estimated to have the potential to trim Utah's $1.4 billion Medicaid budget by $12 million to $14 million.

Utah already qualifies for manufacturer rebates and encourages the use of generic medicines.

But a preferred-drug list goes a step further by replacing brand-name drugs with others that have the same effects, but are not chemically equivalent.

And that's a step that Utah legislators, wooed strongly by drug companies, haven't taken. The list, scheduled for a legislative hearing this month, has been postponed for at least two months.

Legislators blame the delay on scheduling conflicts, and health officials say they need more time to compile data to support the idea. Whatever the cause, there doesn't appear to be a lot of urgency.

"Therapeutic substitutions make people nervous, particularly since we're dealing with a pretty vulnerable population," said state Medicaid Director Michael Diely. "But a lot of other states have done it and the commercial market has done it for years."

Diely says the list would be crafted carefully under the guidance of professional pharmacists and that patients would be able to petition to override it. "People fear they won't get the drugs they need. We're not saying that," said Diely. "We're saying, 'With 90 percent of these drug classes, it doesn't matter whether it's Brand A or Brand B.' ''

kstewart@sltrib.com