The prescription lands at the pharmacy, the pharmacist checks it against the insurance, and it gets rejected.
For many men, that’s when they first realize their insurance covers Viagra (the prescription drug for erectile dysfunction) differently than other medical conditions, like diabetes or high blood pressure. While a doctor may prescribe the medication, coverage is rarely a given.
The short answer is that most insurance plans won’t cover brand-name Viagra. Some may cover the generic version of sildenafil, the active ingredient in Viagra, but with various limitations. It all depends on your specific plan.
Why insurance companies refuse to cover Viagra
Brand-name Viagra is simply too expensive, while the generic equivalent is much cheaper and just as effective.
Some insurance plans may cover ED drugs like sildenafil, but only the generic version, and sometimes with limitations.
Your plan may not cover sexual dysfunction medications at all or only allow a certain number of pills each month. So if your doctor writes a prescription for 30 pills, it may get declined — even if your plan covers four or six.
A denied claim doesn’t necessarily mean sildenafil isn’t covered. It could be that the pharmacy benefit manager wants you to use a different dosage or number of pills, or it may require prior authorization for the prescription to be approved.
Does private insurance cover sildenafil?
It can be, but commercial insurance plans are much more likely to cover the generic version of the medication rather than the brand-name. Even then, there may be various restrictions and requirements, including:
The number of pills covered per month being less than what your doctor prescribed
Prior authorization being needed from your doctor
Higher copays for nonpreferred pharmacies
Use of a preferred generic ED drug before another one via step therapy
No coverage for drugs specifically prescribed for erectile dysfunction
The fastest way to find out if your insurance covers sildenafil is to look up your plan’s formulary online and search for “Viagra” and “sildenafil.” You’ll want to look for any notes that specify QL (quantity limit), PA (prior authorization), or ST (step therapy). You can also give the number on the back of your insurance card a call and ask them about the quantity coverage, copay requirements, and whether or not tadalafil (another ED drug) is preferred. If you’re trying to decide between the two medications, be sure to review our guide on Cialis versus Viagra.
Does Medicare cover Viagra?
Original Medicare (Parts A and B) typically doesn’t cover outpatient medications like Viagra. Part D plans normally don’t cover drugs when they’re prescribed for erectile dysfunction. There may be some coverage under Medicare Advantage or Part D plans, but brand-name Viagra is generally not covered.
It can depend on the diagnosis, too, because sildenafil is also used to treat pulmonary arterial hypertension, which is a serious condition that affects the lungs and the heart. Medicare may cover the drug if it’s prescribed for that specific ailment, even if it’s not covered when it’s prescribed for ED.
Doctors shouldn’t alter a diagnosis to get a medication covered. If an insurance company suspects “upcoding” or “staging,” they may ask for proof that the medication was actually prescribed for the noted reason.
Does Medicaid cover sildenafil?
Medicaid coverage for ED drugs tends to be sparse. Some state programs may cover the generic version of sildenafil, but it’s typically only when it’s prescribed for pulmonary arterial hypertension, rather than erectile dysfunction.
Each state’s Medicaid program is run independently, so it can be hard to sort through the various rules and restrictions. It’s best to contact the specific Medicaid office of your state to ask about coverage rather than searching online.
What can you do if your claim was denied?
Ask the pharmacist for the cash price for the generic sildenafil. It can be much cheaper than using insurance, particularly if you have a discount card you can use at the register. A coupon can’t be used in combination with insurance, so ask the pharmacist to compare the two prices.
Another thing your doctor could do is:
- Write the prescription for the number of pills that your insurance plan covers
- Get prior authorization from your plan
- Write the prescription for the generic version of sildenafil
- Write the prescription for the generic version of tadalafil if it’s a preferred medication
- Appeal the decision if there’s a documented medical reason
Buying “herbal Viagra” or other unregulated sexual enhancement drugs isn’t a good idea, either. The FDA has found numerous counterfeit pills that contain either sildenafil or tadalafil, but with unknown dosages, so you could be putting your health at risk.
Insurance coverage for sildenafil can be inconsistent, but the medication itself shouldn’t be inaccessible or unaffordable. For most men, asking around about the generic version of sildenafil (and asking about the cash price when picking up the prescription) is the best place to start.
