Medicare Part D covers erectile dysfunction drugs, but not all plans cover them equally

Medicare Part D (prescription drug coverage) does cover medications for erectile dysfunction, including sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). However, whether your specific plan pays for it depends on which Part D plan you chose and what that plan's formulary — its list of covered drugs — includes. Some plans cover these medications with a copay. Others require you to pay a higher copay or coinsurance. A few plans do not cover them at all.

Your plan's coverage also depends on whether your doctor prescribes the medication for erectile dysfunction itself or for another condition. Medicare Part D is more likely to cover these drugs when prescribed for pulmonary hypertension or benign prostatic hyperplasia (enlarged prostate) than when prescribed solely for erectile dysfunction, though this varies by plan.

Key Takeaways

  • Medicare Part D covers erectile dysfunction medications, but coverage varies by plan and may require a higher copay than other prescriptions.
  • Your plan's formulary determines whether the specific medication your doctor prescribes is covered and at what cost to you.
  • You can check your plan's coverage by calling the plan directly, visiting its website, or using the Medicare Plan Finder tool.
  • If your plan does not cover the medication or the copay is too high, you may be able to switch plans during the annual open enrollment period in October and November.
  • Generic versions of these medications are usually less expensive than brand-name drugs and may have lower copays.

How to find out what your plan covers

The fastest way to learn whether your Part D plan covers a specific erectile dysfunction medication is to call your plan's customer service number. That number is on the back of your insurance card. Have your plan name and member ID ready. Tell them the medication your doctor prescribed and ask what your copay or coinsurance would be.

You can also check your plan's website. Most plans post their formulary online, organized by medication name. Search for the drug your doctor recommended. The formulary will tell you the tier (cost level) and whether any restrictions explore, such as prior authorization — a requirement that your doctor get approval from the plan before it will pay.

If you do not yet have a Part D plan and are comparing options, use the Medicare Plan Finder at Medicare.gov. Enter the medications you take, including the erectile dysfunction drug your doctor recommends, and the tool will show you which plans cover it and what the costs would be.

What affects your out-of-pocket cost

Your copay or coinsurance for an erectile dysfunction medication depends on which tier the plan places it on. Tier 1 drugs (generic medications) usually have the lowest copay — often $5 to $15 per prescription. Tier 2 (preferred brand-name drugs) may cost $25 to $50. Tier 3 (non-preferred brand-name drugs) can be $50 to $100 or more per prescription.

Generic sildenafil (the active ingredient in Viagra) is usually on a lower tier than brand-name Viagra, so your copay would be less. The same is true for generic tadalafil compared to brand-name Cialis. Ask your doctor whether a generic version would work for you, since the active ingredient is the same.

Some plans also require prior authorization before they will pay for these medications. This means your doctor must contact the plan and explain why the medication is medically necessary. The process usually takes a few business days. If the plan denies the request, your doctor can appeal or suggest an alternative medication the plan does cover.

What to do if your plan does not cover it or the cost is too high

If your current Part D plan does not cover the medication your doctor prescribed, or if the copay is more than you can afford, 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 that does cover it. The Medicare Plan Finder tool will show you which plans in your area cover the specific medication and what the costs would be.

If you are outside the open enrollment period, you may still be able to switch if you have a may have access to life event, such as a move to a new state, loss of other insurance, or a significant change in your income. Contact Medicare at 1-800-MEDICARE to ask whether you may have access to.

Another option is to ask your doctor whether a different erectile dysfunction medication might work for you — one that your plan does cover. Different medications work differently for different people, so switching may be worth trying. Your doctor can also contact your plan to request an exception, asking the plan to cover a non-formulary drug or waive a prior authorization requirement. Plans sometimes grant these requests if the doctor provides medical justification.

Medicare Advantage and erectile dysfunction coverage

If you have Medicare Advantage (Part C) instead of Original Medicare with a separate Part D plan, your coverage for erectile dysfunction medications comes through your Advantage plan's pharmacy benefit. Coverage varies widely among Advantage plans. Some cover these medications generously; others do not cover them at all or require very high copays.

Check your Advantage plan's formulary the same way you would check a Part D plan's — by calling customer service or visiting the plan's website. If your current Advantage plan does not cover the medication adequately, you can switch to a different Advantage plan or switch back to Original Medicare with a Part D plan during the annual open enrollment period.

Questions to ask your doctor

Before your doctor writes a prescription, ask whether the medication is covered by your Medicare plan and what your copay would be. If you are not sure which plan you have, bring your insurance card to the appointment. Your doctor's office staff can often check coverage for you while you wait.

Ask your doctor whether a generic version is available and whether it would work as well as the brand-name drug for your situation. Ask whether there are other medications in the same class that your plan covers at a lower cost. If your plan requires prior authorization, ask your doctor's office to submit the request and let you know how long it will take.

When to contact Medicare directly

Contact Medicare at 1-800-MEDICARE if you have questions about whether your plan should cover a medication and it is not clear from the plan's website or customer service line. Medicare can explain your coverage rights and help you understand your options if you want to switch plans.

If you believe your plan wrongly denied coverage for a medication your doctor prescribed, you have the right to appeal. Your plan must tell you how to file an appeal when it denies a claim. The appeal process usually takes 30 to 60 days. Your doctor can support your appeal by writing a letter explaining why the medication is medically necessary for you.

Frequently Asked Questions

Does Medicare Part B cover erectile dysfunction medications?

No. Part B covers doctor visits and some medical equipment, but not prescription drugs taken at home. Only Part D (prescription drug coverage) covers these medications. If you have Original Medicare, you must have a separate Part D plan. If you have Medicare Advantage, the pharmacy benefit is included in that plan.

Will my copay be the same every month?

Yes, as long as you stay in the same plan and your plan does not change its formulary. However, plans can change their formularies once a year, usually in January. If your medication moves to a higher tier or is removed from the formulary, your plan must notify you in advance so you have time to talk to your doctor about alternatives.

Can I get a 90-day supply instead of a 30-day supply to save money?

Many Part D plans offer mail-order pharmacy services that allow you to get a 90-day supply at a lower total cost than three 30-day supplies. Ask your plan whether this option is available and whether it would reduce your out-of-pocket cost for this medication. Some plans charge the same copay for 90 days as for 30 days.

What if I cannot afford the copay even with Medicare?

Pharmaceutical companies that make these medications sometimes offer patient information programs that reduce the cost for people with limited income. Ask your doctor or pharmacist whether the manufacturer of your prescribed medication has a program. You can also contact your local Area Agency on Aging to ask about other resources that might help with medication costs.

Does Medicare cover this medication if my doctor prescribes it for a different reason, like pulmonary hypertension?

Yes. Medicare Part D is more likely to cover these medications without restrictions when prescribed for pulmonary hypertension or benign prostatic hyperplasia than when prescribed for erectile dysfunction alone. Check your specific plan's formulary or call your plan to confirm coverage for the condition your doctor is treating.