Does Medicare cover Viagra?

By Medicare Benefits - December 19, 2020

Viagra is an FDA-approved drug developed for the treatment of erectile dysfunction (ED), a common male affliction. The generic name for Viagra is sildenafil. Over 65 million prescriptions for Viagra have been filled since it was first introduced in 1998.

People with ED are often treated by urologists. If it is not a medical issue, neither Medicare nor Medicaid would cover the cost of Viagra. Your doctor may recommend counseling or lifestyle adjustments, such as smoking cessation, alcohol intake limitation, physical activity or weight management. But if you have an underlying medical condition, such as circulatory or nerve problems, your doctor would likely prescribe medication.  

Medicare Part D

Original Medicare includes Part A and Part B, but it does not include coverage for prescription drugs. To obtain prescription drug coverage, you would enroll in Medicare Part D plan, either through a stand-alone Medicare Prescription Drug Plan (PDP) or a plan like Medicare Advantage that offers drug coverage as a component of the overall health insurance package. Either way, you have to reside in the service area of the drug plan you are joining, and coverage is contingent on the drug being medically necessary.  

Most of these plans have a proprietary list of covered drugs, referred to as a formulary. The formulary includes brand-name and generic drugs, typically displayed in tiers. The tiers are reflective of the cost of the drugs. Be aware that the formulary can change. Effective 2019, drug plans are permitted to remove brand-name drugs from their list, replacing them with generic products. They can also modify the cost or rules of coverage.  

Medicaid coverage for Viagra

Medicaid is a federal program administered by state governments. Outside of strict adherence to certain federal requirements, the states do have some flexibility on coverage and qualification criteria. The 1990 Omnibus Budget Reconciliation Act stipulates that if a state includes outpatient drugs as part of its Medicaid program, it must cover all medically necessary FDA-approved prescription drugs. There are exceptions to this rule, but Viagra is not one of them. According to the Department of Health & Human Services, "the law requires that a state's Medicaid program cover Viagra when medical necessity dictates such coverage for the drug's medically accepted indication." 

Dual-eligibles 

There are people who are covered by Medicare and Medicaid. This group is referred to as dual-eligible beneficiaries, duals or dual-eligibles. There are full duals and partial duals, which indicates the level of Medicaid benefits allowed. If you are a Medicare recipient with full Medicaid coverage, your prescription drugs would be covered under the drug plan you choose to enroll in. In some cases, Medicaid may cover prescription drugs that Medicare does not.  

Resources

The Urology Care Foundation, at https://www.urologyhealth.org/urologic-conditions/erectile-dysfunction(ed), explains the condition, symptoms, causes, diagnosis and treatment. The National Institute of Health, at https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/treatment, is also a trusted resource. 

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