golf asked
Why won't Medicare cover tadalafil (Cialis) for ED?
At a glance
- Drugs being used for the treatment of erectile dysfunction are not covered under Medicare Part D law. However, if they are being used for other FDA-approved indications (like BPH or pulmonary hypertension), they may be covered.
Answer
The simple answer as to why Medicare doesn't cover any drug for the treatment of erectile dysfunction is because they are specifically listed as excluded in the laws that govern Part D prescription drug coverage.[1]
In fact, there are several categories of drugs that are not covered under Medicare, including ones for weight loss, fertility, and cosmetic purposes, so erectile dysfunction drugs aren't the only ones.
Which drugs are covered, and which are excluded, is based on several factors, including:
- Cost-effectiveness
- Efficacy
- Therapeutic advantage (over other drugs)
- Safety
- Medical Necessity
Unfortunately, drugs used to treat erectile dysfunction are excluded from Part D coverage not only due to their cost, but also the lack of medical necessity when it comes to overall health (although this point has been debated in many scholarly articles).[2]
Where In The Law Does It Say They Aren't Covered?
Coverage requirements for Medicare Part D drugs are defined in the Title XVIII of the Social Security Act. Also listed in the Social Security Act (section 1927(d)(2)) are drugs that are excluded from coverage.[3]
Drugs that are excluded from coverage (according to the SSA act) are:
- Those used for anorexia, weight loss, or weight gain.
- Those used to promote fertility.
- Those used for cosmetic purposes or hair growth.
- Those used for the symptomatic relief of cough and colds.
- Those used to promote smoking cessation.
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
- Non-prescription drugs
- Barbiturates
- Benzodiazepines
- Those used for the treatment of sexual or erectile dysfunction (unless used for a condition other than erectile dysfunction).
There are some exceptions to the above list.
Part D law states that benzodiazepines and barbiturates are now covered (as of 2016) when being used for FDA-approved indications. Smoking cessation products are covered as well.
Unfortunately, drugs for erectile dysfunction are still not covered. These include:
- Viagra (sildenafil)
- Cialis (tadalafil)
- Levitra (vardenafil)
The following is an excerpt from the 'Medicare Prescription Drug Benefit Manual Chapter 6 – Part D Drugs and Formulary Requirements' regarding erectile dysfunction drugs:[4]
References
- ^ MEDICARE PRESCRIPTION DRUG, IMPROVEMENT, AND MODERNIZATION ACT OF 2003. Congress.gov
- ^ Where cost, medical necessity, and morality meet: should US government insurance programs pay for erectile dysfunction drugs? PubMed
- ^ Social Security Act Section 1927 Compilation Of The Social Security Laws
- ^ Medicare Prescription Drug Benefit Manual Chapter 6 – Part D Drugs and Formulary Requirements. CMS
- ^ Revatio Prescribing Information
- ^ Cialis Prescribing Information
