Medicare Part B covers erectile dysfunction drugs, but only under specific conditions

Medicare Part B will pay for erectile dysfunction medications if a doctor prescribes them for a medical reason beyond erectile dysfunction itself. The most common scenario is when these drugs treat pulmonary hypertension or other heart and lung conditions. If your doctor prescribes sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) solely for erectile dysfunction, Medicare does not cover the cost.

This distinction matters because the same medication can be covered or not covered depending on the diagnosis code your doctor uses. A prescription for the same pill might be covered if it treats a recognized condition on Medicare's list, and not covered if it treats only erectile dysfunction.

Your out-of-pocket cost depends on whether you have reached your Part B deductible and whether you use a Medicare Advantage plan instead of Original Medicare. Most people pay 20% of the approved amount after the deductible, but the actual price varies by pharmacy and by which specific drug your doctor prescribes.

Key Takeaways

  • Medicare Part B covers erectile dysfunction drugs only when prescribed for conditions like pulmonary hypertension, not for erectile dysfunction alone.
  • The diagnosis code your doctor enters determines coverage, so the same medication may or may not be covered depending on why it is prescribed.
  • If coverage applies, you typically pay 20% of the approved amount after meeting your Part B deductible.
  • Medicare Advantage plans set their own coverage rules, so check your plan documents or call the plan directly to learn what it covers.
  • If Medicare does not cover the drug, you can often find lower prices through pharmacy discount programs or manufacturer coupons.

When Medicare Part B will cover these drugs

Medicare covers sildenafil, tadalafil, and vardenafil when they treat pulmonary arterial hypertension — high blood pressure in the arteries of the lungs. These medications relax blood vessel walls and improve blood flow, which helps both conditions. Your doctor must document that you have this diagnosis and that the medication is medically necessary to treat it.

Some Medicare coverage also applies when these drugs treat other specific heart and circulatory conditions, though pulmonary hypertension is the most common covered use. Your doctor's office can check whether your particular diagnosis and prescription will be covered by calling Medicare or checking the Medicare website before you fill the prescription.

Coverage also depends on whether the drug is on Medicare's formulary — the official list of covered medications. All three common erectile dysfunction drugs are on the formulary, but your specific Medicare Advantage plan may have additional restrictions or requirements, such as prior authorization from the plan before you fill the prescription.

How to find out what your plan covers

If you have Original Medicare (Part A and Part B), call Medicare at 1-800-MEDICARE (1-800-633-4227) and tell them your diagnosis and the medication your doctor prescribed. They can tell you whether that specific prescription will be covered and what you will pay. Have your doctor's name and the exact medication name and dose ready when you call.

If you have a Medicare Advantage plan, call the plan's customer service number on the back of your insurance card. Ask whether the drug is covered for your diagnosis and whether you need prior authorization — approval from the plan before the pharmacy fills the prescription. Prior authorization can take a few days, so ask how long it usually takes and whether your doctor's office can submit the request.

Your pharmacy can also check coverage for you. When you take a prescription to the pharmacy, the pharmacist can run it through your insurance and tell you when ready whether it is covered and what you will pay. If it is not covered, ask the pharmacist about generic versions or lower-cost alternatives.

What you pay if Medicare covers the drug

If your prescription is covered under Original Medicare Part B, you pay 20% of the approved amount after you have met your yearly Part B deductible. The deductible for 2024 is $240, though this amount changes each year. Once you reach the deductible, you pay 20% of what Medicare approves for the drug.

The approved amount varies by pharmacy and by which specific drug you use. A month's supply of one medication might cost you $15 to $40 out of pocket, while another costs more. Ask your pharmacy for the exact price before you fill the prescription, or ask your doctor whether a generic version might cost less.

If you have a Medicare Advantage plan, your cost depends on your plan's formulary and your plan's copay or coinsurance structure. Some plans charge a flat copay (for example, $10 per prescription), while others charge a percentage of the cost. Check your plan documents or call the plan to learn your exact cost.

What to do if Medicare does not cover the drug

If your prescription is not covered because you are taking it for erectile dysfunction alone, you have several options. Many pharmacies offer discount programs that reduce the price without using insurance. GoodRx, SingleCare, and RxSaver are free websites and apps where you can compare prices at different pharmacies and sometimes find discounts of 30% to 50% off the regular price.

Manufacturer coupons can also lower the cost. Pfizer (which makes Viagra), Eli Lilly (which makes Cialis), and other manufacturers sometimes offer coupons that reduce the out-of-pocket price. Ask your doctor or pharmacist whether a coupon is available for the specific drug prescribed.

Generic versions of these drugs are usually less expensive than brand-name versions. Ask your doctor whether a generic is appropriate for your situation, and ask your pharmacy to fill the generic if your doctor approves. Generic sildenafil, for example, often costs significantly less than Viagra.

Talking with your doctor about coverage

Before your doctor writes a prescription, tell them whether you have Medicare and ask whether the medication will be covered. Your doctor's office staff often knows which diagnoses Medicare covers and can help you understand whether your situation qualifies. If the drug is not covered, ask your doctor whether there are other treatment options or whether they recommend trying a discount program.

If your doctor prescribes the medication, ask for the generic name (sildenafil, tadalafil, or vardenafil) rather than the brand name if possible. Generic versions are usually covered the same way as brand names but cost less. Also ask your doctor to write "do not substitute" on the prescription only if there is a medical reason — otherwise, the pharmacy can fill a generic version automatically.

Your doctor can also help you understand whether the medication is truly necessary for your condition or whether other treatments might work. If cost is a concern, tell your doctor directly. They may know about programs, samples, or alternatives that could help.

Medicare Advantage plans and erectile dysfunction drugs

Medicare Advantage plans (Part C) set their own coverage rules and may cover or exclude erectile dysfunction drugs differently than Original Medicare. Some plans cover these drugs for erectile dysfunction alone, while others follow the same rules as Original Medicare and cover them only for other conditions. You need to check your specific plan's formulary to know what applies to you.

To find your plan's coverage, log into your plan's website or call the customer service number on your insurance card. Ask specifically whether the drug is covered for your diagnosis and what your copay or coinsurance will be. If the drug is not covered, ask whether the plan covers any alternative medications for the same condition.

Frequently Asked Questions

Does Medicare cover Viagra, Cialis, or Levitra for erectile dysfunction?

No. Medicare Part B does not cover these drugs when prescribed solely for erectile dysfunction. Coverage applies only when a doctor prescribes them for other conditions, most commonly pulmonary hypertension. Your Medicare Advantage plan may have different rules, so check your plan documents.

What if my doctor says I need this drug for my heart condition?

Tell your doctor to include the heart or lung condition diagnosis when writing the prescription. Medicare uses the diagnosis code to determine coverage. Your doctor's office can verify coverage before you fill the prescription by calling Medicare or checking the Medicare website.

How much will I pay if Medicare covers the drug?

You pay 20% of the approved amount after meeting your yearly Part B deductible ($240 in 2024). The actual cost depends on the specific drug and your pharmacy. Ask your pharmacy for the exact price before filling the prescription.

Can I use a discount program if Medicare does not cover it?

Yes. Websites like GoodRx, SingleCare, and RxSaver let you compare prices and often find discounts of 30% to 50%. Manufacturer coupons and generic versions also reduce cost. These programs work whether or not you have insurance.

Will my Medicare Advantage plan cover this drug?

It depends on your specific plan. Call the customer service number on your insurance card and ask whether the drug is covered for your diagnosis. Medicare Advantage plans set their own formularies and may cover drugs that Original Medicare does not.