Is Cialis Covered by Insurance?

Cialis (tadalafil) is a phosphodiesterase type 5 (PDE5) inhibitor used for the treatment of erectile dysfunction (ED) and benign prostatic hyperplasia in men. This smooth muscle relaxant is similar to Pfizer’s Viagra and Bayer’s Levitra; all three medications belong to the same drug class. Most ED drugs are not covered by insurance. In 2014, Levitra was dropped by Express Scripts and Caremark, two giant companies that handle pharmacy benefits. In 2016, Viagra have also been excluded in their list of covered drugs. In general, Medicare plans do not cover erectile dysfunction drugs including Cialis.

2018 formulary changes for erectile dysfunction drugs

Express Scripts

CVS Caremark

- Still covers Cialis and generic Viagra (sildenafil)
- Excludes Levitra and Staxyn

- Levitra is being added back from non-preferred status
- Still covers Cialis
- Does not cover Viagra

Private and government companies in the US launch various health insurance programs with prescription medication coverage benefits. These health insurance plans aim to cover some expenses for essential prescription meds. As of 2016, there are approximately 53 million citizens, ages 65 and older, who are under the government-organized Medicare coverage program. Over 200 million citizens are under employer-based insurance from private companies. In the UK, health insurance policies are provided by the government (National Health Service and Health Care System), thus insurance from private corporations only account to a small portion of the country’s population.

Pharmacy benefit managers on ED drugs

Express Scripts and CVS/Caremark are pharmacy benefit managers (PBM) or companies that handle pharmacy benefits for many health insurance companies. Even if you have a private insurer (e.g., Aetna or Anthem), your prescription drug benefits are usually handled by these two corporations or their rival companies. Around 180 million enrollees are covered by three major PBMs in the United States: Express Scripts, CVS Health, and OptumRx under UnitedHealth Group.
Health insurance companies used to pay for erectile dysfunction drugs as long as it was an approved treatment and the disorder was secondary to a diagnosable medical condition. But when federal regulations prohibited Medicare and Medicaid from covering ED drugs, most private health insurance companies followed suit. Some insurance companies still pay for drugs like Cialis, Viagra, or Levitra but they usually limit the number of pills they will cover; for instance, they may choose to provide 8 pills per month for each eligible member.

How do formulary changes affect you?

A drug formulary is a list of generic and brand name prescription drugs that are covered by health insurance plans. The list is prepared by physicians, pharmacists, and other healthcare professionals through a rigorous selection process to ensure that the medications included are the best combination of clinically appropriate and cost-effective treatments. Although Cialis and other prescription drugs is still included in the preferred formulary, it does not mean it will be covered by your insurance plan. Coverage depends on specific prescription benefit plan and certain products or categories available in the formulary may not be part of your insurance coverage. If your drug of choice is not included in the formulary, it means you need to make a full out-of-pocket payment for your prescription drug. Most drugs excluded from PBMs formularies have generic counterparts or equivalent preferred treatments. You should discuss with your doctor if switching to similar drugs or generic version will benefit your condition. With regard to Cialis, Eli Lilly’s patent will set to expire in September 2018, which means generic equivalent of the drug may be available in the near future.

Cialis vs other ED drugs

PDE5 inhibitors are the first line pharmacological treatments for erectile dysfunction. Viagra, Cialis, and Levitra are the most popular medications in this drug class. Cialis is slightly cheaper than the two drugs, but now that generic Viagra is out in the market, the prices for other ED drugs will most likely go down to compete for Pfizer’s and Teva’s generic Viagra (sildenafil). Currently, Cialis is still being covered by CVS/Caremark and Express Scripts. Cialis and Viagra are at Tier 2 in OptumRx drug formulary, while Levitra, Staxyn, and Stendra are excluded. If your doctor prescribed Cialis for your ED, you have two options to choose from. You can take the standard dose of 10–20mg on an “as needed” basis or take a daily dose of 2.5–5mg per day. Tadalafil has the longest duration among all commercially available ED drugs, so daily Cialis is preferred by patients, who expect frequent sexual activity.