Does Medicare cover erectile dysfunction drugs?

Does Medicare Part D cover drugs for erectile dysfunction?

No. CMS's Medicare Prescription Drug Benefit Manual lists agents used for the treatment of sexual or erectile dysfunction among the drugs excluded from Part D coverage. Part D doesn't cover drugs or classes of drugs, or their medical uses, that are excluded from coverage or otherwise restricted under section 1927(d)(2) of the Social Security Act. The same CMS list excludes these drugs and uses from Part D:

• Agents when used for anorexia, weight loss or weight gain, even if used for a non-cosmetic purpose like morbid obesity.
• Agents when used to promote fertility.
• Agents when used for cosmetic purposes or hair growth.
• Agents when used for the symptomatic relief of cough and colds.
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
• Nonprescription drugs.
• Covered outpatient drugs whose manufacturer seeks to require, as a condition of sale, that associated tests or monitoring services be bought only from the manufacturer or its designee.
• Agents when used for the treatment of sexual or erectile dysfunction.

When can Part D cover an erectile dysfunction drug?

Only when it's prescribed for a different use the FDA has approved. CMS says ED drugs meet the definition of a Part D drug when they're prescribed for medically accepted indications approved by the FDA other than sexual or erectile dysfunction, such as pulmonary hypertension.

ED drugs don't meet the definition of a Part D drug when they're used off-label, even when the off-label use is listed in one of the recognized drug compendia (the American Hospital Formulary Service Drug Information and the DRUGDEX Information System). CMS's manual says ED drugs meet the definition of a Part D drug only when used for FDA-approved indications.

How does a Medicare drug plan check what a drug is used for?

CMS makes Part D plans responsible for making sure covered Part D drugs are prescribed for medically accepted indications. During a member's transition period, CMS lets plans use edits to prevent coverage of non-Part D drugs, and the manual gives a drug that may be used for sexual dysfunction as an example. Medicare.gov says plans may use prior authorization when they only cover a drug for certain medical conditions, but not others.

When you're in a plan, you have the right to a coverage determination to see if a drug is covered. If you disagree with the plan's decision, you can appeal; you, your representative or your prescriber must ask within 65 days from the date on the plan's denial notice. See how to appeal a Medicare decision.

Can a Medicare drug plan cover ED drugs as an extra benefit?

CMS's rules allow it in one plan design. The Part D manual says that while these drugs or uses are excluded from basic Part D coverage, Part D plans can generally include them as part of supplemental benefits, provided they otherwise meet the definition of a Part D drug. A plan may cover these supplemental drugs only as a supplemental benefit under enhanced alternative coverage.

Each plan has its own list of covered drugs (formulary), so check the plan's drug list before you join. Most Medicare Advantage plans include Medicare drug coverage (Part D), and Medicare Advantage plans may also offer extra benefits that Original Medicare doesn't cover; rules and costs vary by plan.

Does Original Medicare or Medigap pay for ED drugs?

Original Medicare's drug coverage is limited. Medicare Part B covers a limited number of outpatient prescription drugs under certain conditions, usually drugs you wouldn't typically give to yourself, like those you get at a doctor's office or in a hospital outpatient setting. Medicare drug coverage (Part D) covers many drugs that Part B doesn't cover.

Medigap plans sold after 2005 don't include prescription drug coverage. If you have Original Medicare and want drug coverage, you can join a separate Medicare drug plan (Part D); see how Medicare covers prescription drugs.