Medicare's Coverage of Erectile Dysfunction Drugs

Medicare Part D (prescription drug coverage) covers erectile dysfunction medications including Viagra, but only if your doctor prescribes them for medical reasons and you are enrolled in a plan that includes that drug on its formulary. Not every Part D plan covers these medications the same way — some may require you to try a lower-cost alternative first, some may charge a higher copay, and some may not cover them at all. Original Medicare (Parts A and B) does not cover prescription drugs, so you need Part D or a Medicare Advantage plan with drug coverage to get any coverage at all.

The amount you pay depends on which plan you chose during open enrollment and where the drug falls on that plan's formulary — the list of covered medications organized by cost tier. Viagra typically falls into a higher tier because it is a brand-name drug, which usually means a higher copay than generic alternatives like sildenafil.

Key Takeaways

  • Medicare Part D covers Viagra and other erectile dysfunction drugs only if your plan's formulary includes them and your doctor writes a prescription for a medical reason.
  • Generic sildenafil (the active ingredient in Viagra) is usually cheaper than brand-name Viagra and is covered by most Part D plans at a lower copay.
  • Your copay for these medications varies by plan and by which tier the drug sits on — you can check your plan's formulary on Medicare.gov or call your plan directly.
  • Some plans require prior authorization or step therapy, meaning your doctor may need to document that you tried a lower-cost option first before the plan will cover the brand name.
  • If your current plan does not cover the drug you need, you can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7).

How to Find Out What Your Specific Plan Covers

The fastest way to learn what your plan covers is to call the customer service number on the back of your Medicare card. Have your doctor's name and the medication name ready, and ask three things: whether the drug is on the formulary, what tier it is on, and whether your plan requires prior authorization or step therapy.

You can also search your plan's formulary yourself on Medicare.gov. Go to the Plan Finder tool, enter your zip code and current plan name, and look for the drug name in the formulary. The tool will show you the copay amount and any restrictions. If you do not have internet access, call 1-800-MEDICARE and a representative can look it up for you.

Generic Sildenafil vs. Brand-Name Viagra

Generic sildenafil is the same medication as Viagra but costs much less. Most Medicare Part D plans cover generic sildenafil at a lower copay than brand-name Viagra because generics are cheaper for the plan. If your doctor prescribes Viagra by brand name, ask whether sildenafil would work for you instead — it is chemically identical and usually covered at a tier 1 or tier 2 copay instead of tier 3 or 4.

If you have already tried sildenafil and it did not work for you, or if you have a medical reason to use the brand name, your doctor can request an exception from your plan. This is called a formulary exception, and the plan will review your doctor's request and decide whether to cover the brand name anyway. The process usually takes a few business days.

Prior Authorization and Step Therapy Requirements

Some Medicare Part D plans require prior authorization before they will cover erectile dysfunction medications. This means your doctor has to contact the plan and get approval before you fill the prescription. The plan may ask your doctor to confirm the diagnosis and that the medication is medically necessary. This usually takes one to three business days.

Other plans use step therapy, which means the plan will only cover brand-name Viagra if you have already tried and failed on a lower-cost alternative like generic sildenafil. If your plan has step therapy, your doctor will need to document that you used the generic first and that it did not work before the plan will cover the brand name.

What Happens if Your Plan Does Not Cover It

If your current Part D plan does not cover erectile dysfunction medications at all, or if the copay is too high, you have options. During the annual open enrollment period (October 15 through December 7 each year), you can switch to a different Part D plan or to a Medicare Advantage plan that includes drug coverage. You can compare plans on Medicare.gov and see which ones cover the medication you need and at what copay.

If you need the medication before open enrollment arrives, you can ask your doctor about other treatments or lower-cost alternatives. You can also pay out of pocket at a pharmacy and submit the receipt to your plan to see if they will reimburse you, though most plans will not. Some pharmaceutical companies offer patient information programs that reduce the cost of brand-name medications for people with low incomes — your doctor's office or the drug manufacturer's website can tell you whether you may have access to.

Medicare Advantage Plans and Erectile Dysfunction Coverage

If you are enrolled in a Medicare Advantage plan (Part C), your drug coverage works differently than with Original Medicare plus Part D. Medicare Advantage plans include drug coverage as part of the plan, and each plan has its own formulary. Some Medicare Advantage plans cover erectile dysfunction medications and some do not, so you need to check your specific plan's formulary the same way you would with Part D.

The copay amounts and tier placement may be different in a Medicare Advantage plan than in a standalone Part D plan. If your Medicare Advantage plan does not cover the medication you need, you can switch to Original Medicare plus a Part D plan during open enrollment, though you will lose any other benefits your Medicare Advantage plan offered.

Cost-Saving Strategies

Ask your doctor to prescribe generic sildenafil instead of brand-name Viagra — the copay is usually much lower and the medication is identical. If your plan requires prior authorization, your doctor's office can submit the request while you are still in the exam room, which speeds up the process.

Some pharmacies offer discount programs for medications not covered by insurance or for people who want to avoid a high copay. GoodRx, SingleCare, and similar discount card programs sometimes offer prices lower than your copay, especially for generic sildenafil. You can compare prices at different pharmacies before you fill the prescription. If you have limited income, ask your doctor whether you may have access to for a patient information program from the drug manufacturer.

Frequently Asked Questions

Does Original Medicare cover Viagra without Part D?

No. Original Medicare (Parts A and B) does not cover any prescription drugs. You must have Part D or a Medicare Advantage plan with drug coverage to get coverage for Viagra or any other prescription medication.

Will Medicare cover Viagra if my doctor says it is medically necessary?

Medicare Part D will cover it if your plan's formulary includes it and your doctor prescribes it for a medical reason. The fact that it is medically necessary does not override the plan's formulary — you still need the drug to be on the list. If it is not, you can ask your doctor to request a formulary exception.

Can I switch Part D plans if my current plan does not cover erectile dysfunction medications?

Yes, during the annual open enrollment period (October 15 to December 7) you can switch to a different Part D plan or to a Medicare Advantage plan. You can compare plans on Medicare.gov to see which ones cover the medication you need and at what copay.

Is generic sildenafil covered the same way as Viagra?

Generic sildenafil is usually covered at a lower copay than brand-name Viagra because it costs the plan less. Most Part D plans place sildenafil on a lower tier. Ask your doctor whether sildenafil would work for you instead of the brand name.

What if I cannot afford the copay?

Compare prices at different pharmacies using GoodRx or similar discount programs — sometimes the discount price is lower than your copay. Ask your doctor whether you may have access to for a patient information program from the manufacturer. If you have limited income, you may may have access to for Extra Help, a program that lowers Part D copays.