How to Understand Medicare and Viagra Cost and Coverage

• Viagra (sildenafil citrate) is brand name drug used to treat erectile dysfunction. 

• While Original Medicare does not include prescription drug coverage, beneficiaries can enroll in a separate drug plan known as Medicare Part D. A Medicare Advantage plan may also include prescription drug coverage.

• Medicare Part D plans do not cover brand name Viagra. These drug plans cover plans will generic viagra, however.

• There are ways to help individuals combat high prescription drug costs, including GoodRx, Medicaid, Extra Help program, etc.

Erectile dysfunction (ED) is a health condition in which the penis can not obtain or sustain an erection. It is a form of sexual dysfunction and vascular disease. Erectile dysfunction drugs, also known as ED drugs, are often used to treat ED. One of the most common and well-known ED medications is Viagra.

Viagra is a phosphodiesterase‑5 enzyme (PDE‑5) inhibitor, meaning it blocks PDE‑5. This helps relax certain muscles and blood vessels. In turn, this increases blood flow to the penis to help get and maintain an erection.

Although generally most patients start at the lower 25 mg dose, Viagra is most often taken as a 50 mg tablet one hour prior to sexual intercourse. This dose can be adjusted from 25 mg to 100 mg depending on the patient’s reaction to the medication and cardiovascular risk. No more than one tablet of Viagra should be taken on a given day, no matter the patient’s dosage.

Side Effects

Common side effects include: 

• Headaches

• Flushing

• Indigestion

• Blurred vision

• Light sensitivity

• Nasal congestion

Viagra may also cause back pain, muscle aches, nausea, dizziness, and a rash in some individuals. If a patient experiences any of the following side effects, they should contact a doctor immediately as these can be life-threatening: 

• An erection lasting for more than four hours

• Vision loss

• Hearing loss

• Chest pain or blood pressure changes

Who Should Not Take Viagra? 

Certain people should not take Viagra. These include:

• People with certain existing heart conditions

• Abnormal blood pressure

• Men with history of angina or unstable chest pain

• Those taking other medications that may cause interaction

Medicare beneficiaries should always inform their medical provider of their medical history to make sure they are not more susceptible to adverse outcomes, including a list of current medications.

Without health insurance, Viagra runs around $1,180.22.

Original Medicare only consists of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Original Medicare coverage does not include prescription drugs such as Viagra. As such, those who only have an Original Medicare plan need to enroll in a Medicare drug plan, known as Medicare Part D, in order to receive prescription drug coverage.

Medicare Part D is Medicare’s prescription drug coverage. Most Medicare prescription drug plans include a monthly premium, yearly deductible, copayments, and coinsurance. Medicare drug plans’ overall costs will vary. Factors that contribute to costs include: 

• Prescriptions: What prescriptions a beneficiary needs and whether they’re on the drug plan’s list of covered medications, known as the plan’s formulary can affect cost.

• Medication Tier: What tier the medication is in can affect the plan’s cost. Most plans have five tiers and the higher the tier, the more expensive a medication usually is. Tier information is provided on the plan’s formulary. 

• Drug Benefit Phase: Which drug benefit phase the beneficiary is in can affect the plan’s cost, i.e. whether they’ve paid their deductible or if they’re in the catastrophic coverage phase.

• Pharmacy: What pharmacy type and location impact Part D’s cost. 

• Medicare Extra Help Enrollment: Whether a beneficiary is enrolled in the Medicare Extra Help program can impact their Part D cost.

Medicare enrollees are encouraged to compare Medicare prescription drug plans to find the best option for them.

Note: Learn more about Medicare Part D costs at this resource.

Does Medicare Part D Cover Viagra? 

Most Medicare prescription drug plans do not cover the brand name version of Viagra. That said, coverage and cost will still depend on the specific Medicare Part D plan chosen. Beneficiaries should consult their insurance provider.

Does Medicare Part D Cover Generic Sildenafil? 

Yes, most Medicare Part D plans cover generic sildenafil. Sildenafil is typically a Tier 2 medication. There is a copay, which will be dependent on the beneficiary’s coverage stage. For example, those who have met their Part D deductible will pay between $1–$10 for sildenafil.

Quantity limits and prior authorization may apply. A quantity limit is how much medication a beneficiary can fill at one time. Prior authorization is when an insurance company requires healthcare providers to seek approval from the patient’s insurance company before a medication or other healthcare service will be covered.

Note: Learn more about sildenafil and Medicare coverage at this resource.

Medicare Advantage plans, also known as Medicare Part C or MA plans, are Medicare supplement insurance plans. MA plans are provided by private insurance companies that are Medicare-approved. Medicare Part C plans consist of the standard Medicare coverage (Medicare Part A and Medicare Part B), in addition to other healthcare benefits including vision, hearing, and prescription drugs. Exact benefits will vary per plan and beneficiaries should confirm extra benefits with their health insurance provider.

Some Medicare Part C plans may cover brand name Viagra. However, again, it will depend on the specific MA plan chosen since not all Medicare Advantage plans include coverage for prescription drugs. If an MA plan does include prescription drug coverage, beneficiaries can look at their plan’s formulary for a list of covered drugs to see if Viagra is included.

Out of pocket costs for prescription medications can add up quickly, even with health insurance coverage. There are a number of programs that can help Medicare beneficiaries with these drug costs, however.

Extra Help Program 

The Extra Help Program is a Medicare program to help beneficiaries with limited income or resources pay for a Medicare prescription drug plan. Some people automatically will qualify for Extra Help, such as those who qualify for the QMB program, SLMB, or QI program under Medicare Savings Programs.

Those who do not automatically qualify can apply here.

SHIP

The State Health Insurance Assistance Program (SHIP) is a national program that helps Medicare beneficiaries, caregivers, and family members make informed choices about their Medicare benefits and navigate all of their options. 

Note: Learn more about SHIP at this resource.

GoodRx

GoodRx is both a website and mobile application that finds discount pricing for prescription medications that helps people save money on prescription medications. Visit its Viagra page to learn more.

Medicaid (Dual Eligibles)

Beneficiaries eligible for the Medicaid ​“Dual Eligibles” program will be eligible to use the Medicaid Drug Rebate Program (MDRP). This program helps to offset the Federal and state costs for prescription drugs. 

Note: Learn more about Medicaid Drug Rebate Program at this resource.

PACE

PACE stands for Program of All-Inclusive Care for the Elderly. It is a Medicare and Medicaid program that provides all the care and services covered by Medicare and Medicaid if authorized by someone’s health care team. This includes prescription drugs. Those in a PACE program do not need to enroll in a separate Medicare Part D drug plan.

Note: Learn more about PACE at this resource.

Medicare Supplement Plans

Medicare supplement insurance plans, also known as Medigap or MedSupp plans, are Medicare plans that intend to ​“fill in the gaps” of Original Medicare. A MedSupp or Medigap plan will often help with deductible, copayment, and coinsurance payments.

When it comes to prescription drugs, someone cannot be enrolled in both a Medicare prescription drug plan as well as have a Medigap policy with drug coverage. Learn more about Medigap and Medicare drug coverage at this resource.