Does Insurance Cover ED Medication? Medicare, Plans and Cash Price

Below: what Medicare, Medicaid and private plans do, the exceptions, which online programs take insurance, and when cash beats a copay.

Coverage at a glance

Medicare: the statutory exclusion

Part D's definition of a covered drug carries a carve-out. The law says the term "does not include a drug when used for the treatment of sexual or erectile dysfunction, unless such drug were used to treat a condition, other than sexual or erectile dysfunction, for which the drug has been approved by the Food and Drug Administration." (42 U.S.C. 1395w-102, via Cornell LII)

CMS applies it in its Part D manual: "ED drugs will meet the definition of a Part D drug when prescribed for medically-accepted indications approved by the FDA other than sexual or erectile dysfunction (such as pulmonary hypertension)." The manual adds that "ED drugs will not meet the definition of a Part D drug when used off-label" (CMS Medicare Prescription Drug Benefit Manual, chapter 6).

So the question of whether Medicare covers Viagra has a plain answer: not for ED. Tadalafil is the main exception worth knowing. The Cialis label lists approval for "the signs and symptoms of benign prostatic hyperplasia (BPH)" (DailyMed: Cialis label), so a Part D plan can cover tadalafil prescribed for BPH.

The same statute leaves one door open. A note to the law says nothing in it prevents a plan "from providing coverage of drugs for the treatment of sexual or erectile dysfunction as supplemental prescription drug coverage" (42 U.S.C. 1395w-102). A few enhanced plans may do this; check your plan's formulary.

Medicaid

Federal Medicaid law lets states drop the class. It lists drugs that "may be excluded from coverage or otherwise restricted", including "Agents when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration" (42 U.S.C. 1396r-8). Whether your state covers them is a question for your state Medicaid program.

Private insurance

Employer and marketplace plans are not bound by the Part D exclusion, so the answer depends on the plan. A plan that covers them may still limit tablets per month, require a generic first, or ask for prior authorisation. Look up "sildenafil" and "tadalafil" in your plan's formulary before you assume either way. We could not find a reliable national figure for how many private plans cover ED drugs, so we do not quote one.

Online ED programs and insurance

The programs we track are cash only, and several say so in plain words:

• Rex MD: "While Rex MD does not accept insurance, our telehealth services often cost less than what you would pay using your insurance." (Rex MD FAQ)
• Strut Health: "Strut does not accept insurance and services on Strut are not covered by insurance." (Strut FAQ)
• Henry Meds: "No, you don’t need insurance!" (Henry Meds)

If you want to use insurance, pick a program that sends the prescription out. Lemonaid says its clinicians can "send it to your local pharmacy same day" (Lemonaid Health), where your plan's pharmacy benefit applies. Ro also lets members fill at their own pharmacy. PeterMD accepts FSA and HSA cards, which use pre-tax money but are not insurance; see our PeterMD review.

When cash beats a copay

Generic sildenafil and tadalafil are among the cheapest prescription drugs to buy for cash. At Cost Plus Drugs, a 30-tablet pack of sildenafil was $6.72 and tadalafil 5 mg tablets $5.97 when we checked, before shipping. A copay on a covered generic can be higher than that, and a plan that limits tablets per month may cost you more in time than it saves.

With the visit included, the cheapest all-in plan we track is Strut Health at $16 a month. Our guide to the cheapest ED medication online ranks every per-dose price, and our Cost Plus Drugs guide lists the cash pharmacy prices.