Does Medicare Cover Cialis?

Does Medicare Part D cover Cialis for erectile dysfunction?

Usually, no. Medicare Part D is prescription drug coverage offered through Medicare-approved private plans, but federal rules exclude drugs when they are prescribed for sexual or erectile dysfunction.

Cialis is a brand-name form of tadalafil. If your prescription is specifically for erectile dysfunction, basic Part D coverage generally will not pay for it. You may be responsible for the full cost unless your plan offers a separate supplemental benefit or another source of coverage applies.

Can Cialis ever be covered by Medicare?

Possibly, depending on why it is prescribed. CMS guidance allows erectile dysfunction drugs to meet the definition of a Part D drug when they are prescribed for an FDA-approved use other than sexual or erectile dysfunction.

For example, FDA labeling for Cialis includes treatment of the signs and symptoms of benign prostatic hyperplasia, also called BPH or enlarged prostate. If tadalafil is prescribed for a covered non-ED indication, your Part D plan may cover it if the drug is on the plan formulary and you meet any plan requirements.

What plan rules may apply?

Even when tadalafil may be eligible for coverage, the plan can still apply normal drug coverage rules. These may include:

• Formulary rules: A formulary is the plan’s list of covered drugs.
• Prior authorization: The plan may require your prescriber to confirm the medical reason for the drug before coverage starts.
• Quantity limits: The plan may limit how much of the drug it covers within a certain time period.
• Step therapy: In some cases, the plan may require trying another covered drug first.

If the plan only covers tadalafil for certain diagnoses, the pharmacy or plan may need diagnosis information from your prescriber.

Does Original Medicare cover Cialis?

Original Medicare includes Part A and Part B. These parts generally do not cover most routine outpatient prescription drugs that you pick up at a pharmacy. Medicare.gov explains that Part D covers many outpatient drugs that Part B does not cover, and people with Original Medicare can join a separate Medicare drug plan for drug coverage.

Because Cialis is usually a self-administered outpatient prescription, coverage questions are usually handled under Part D or a Medicare Advantage plan that includes drug coverage.

What if my plan denies Cialis or tadalafil?

If your prescription is denied, first ask whether the denial is because the drug is being used for erectile dysfunction or because of a plan rule such as prior authorization. If your prescriber believes tadalafil is medically necessary for a covered non-ED condition, you or your prescriber can ask the plan for a coverage determination or exception.

If the drug is prescribed only for erectile dysfunction, an exception request may not overcome the federal exclusion for basic Part D coverage. Some enhanced plans may offer supplemental coverage for excluded drugs, but this varies by plan.

How can you check your Cialis coverage?

To check your specific coverage:

1. Look up Cialis and tadalafil in your plan’s formulary.
2. Check whether coverage depends on diagnosis or prior authorization.
3. Ask your prescriber whether the prescription is for ED, BPH, or another medical condition.
4. Call your plan before filling the prescription if the coverage reason is unclear.

Because formularies and plan rules vary, the same drug may be covered under one Medicare drug plan but not another.

Official Sources