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Does Medicare Cover Erectile Dysfunction Treatments?

Oct 08, 2018

Does Medicare Cover Erectile Dysfunction Treatments?

It’s no secret that our bodies change as we age. We might not move as quickly, hear as clearly, or see as vividly as we did when we were younger. But while some changes might seem inevitable, getting older doesn’t mean we’re down for the count.

Sexual function is no different. As men get older, they might start having trouble with erections. It can take longer to get aroused or become more difficult to get a fully firm erection. Older men may also be more prone to health conditions that contribute to poor erections, like low testosterone, diabetes, and heart disease. Treatment for certain types of cancer, like prostate cancer, can affect erections, too.

The good news is that men with erectile dysfunction (ED) have many treatment options available. Pills, self-injections, vacuum erection devices, urethral suppositories, and penile implant surgery are all possibilities.

Unfortunately for older men in the United States, Medicare usually does not cover ED treatments, as they are not considered medically necessary.

Today, we’ll discuss some of the basics of Medicare coverage for ED. Please note that this is a brief summary. Medicare has many components, and we encourage you to see the Medicare website for complete details.

What is Medicare?

Medicare is a health insurance program for people age 65 and older in the United States. People under age 65 may qualify if they have certain disabilities. Patients with end-stage renal disease may be eligible at any age.

Generally, Medicare comes in three main categories:

  • Medicare Part A – This part helps cover people when they are in the hospital.
  • Medicare Part B – This part helps cover doctor’s visits and outpatient services.
  • Medicate Part D – This part covers some, but not all, prescription drugs.

ED and Medicare: A General Overview

Medicare’s ED coverage as of October 2018 is as follows:

Treatment

Examples

Covered?

Medication – Phosphodiesterase type 5 (PDE5) inhibitor pills

Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), Stendra (avanafil)

If prescribed for ED: No

 

If prescribed for another condition: Maybe

Medication – self-injections

Caverject, Edex (papaverine, phentolamine and/or alprostadil)

No

Medication – urethral suppositories

MUSE (alprostadil)

No

Vacuum erection devices

 

No

Penile implant (prosthesis)

 

Under certain circumstances.  See below.  

Note: In general, Medicare covers penile implants when certain criteria are met. Medicare covers penile implants if erectile dysfunction is caused by an underlying medical condition, such as diabetes, coronary artery disease, or Peyronie's disease. It is also covered after radical prostatectomy, a surgical treatment for prostate cancer.

In addition, the patient must try other ED therapies, such as testosterone replacement therapy, injections, or PDE5 inhibitors first. If these approaches do not work, then implants may be covered.

Medications needed in connection with surgery might be covered under Medicare Plan D. 

Replacement of the implant may be covered if it breaks or becomes infected as long as the implant is still medically necessary and is not under warranty.

Patients should always confirm their coverage with their insurance provider before having penile implant procedures.

What can men do?

ED treatments can be expensive, and lack of coverage can be disappointing. But there might still be ways to receive treatment. Here are some steps to consider:

  • Talk to your doctor. ED is linked to a variety of chronic illnesses, such as diabetes and heart disease. Sometimes, treatment for those conditions, or even just changing your lifestyle, alleviates erection problems to some degree. Make sure you are doing everything you can to stay healthy. If you have diabetes, check your blood sugar regularly and follow your doctor’s diet recommendations exactly. If you are overweight, ask your doctor about weight-loss plans and exercise. If you smoke, inquire about smoking cessation programs. Medicare may cover conditions that lead to ED, even if it doesn’t cover ED treatments directly.
  • Talk to your health insurer. Find out if there are any other coverage avenues to try.
  • Look for coupons, discounts, and sales. Some drug manufacturers offer coupons and discounts for their products. For example, as of October 2018, Pfizer, the manufacturer of Viagra, is offering a 50% discount on up to 12 Viagra prescriptions per year. Pfizer also offers an assistance program. Other manufacturers might offer similar deals. Your pharmacist may know of other discount programs. Be sure to ask.
  • Consider contacting your State Pharmaceutical Assistance Program. Some states have programs that help their residents pay for their medications. Eligibility can vary from state to state. See more informationhere.

Remember…

While Medicare is fairly standard, people’s individual situations are different. What is covered for your neighbor might not necessarily be covered for you - and vice versa - so it’s always important to double check your benefits with Medicare and any other insurance organization.

Medicare planning can be quite complex, and rules can change. If you need help, don’t hesitate to contact Medicare directly. (You’ll also find information translated into over 20 languages.) You might also contact organizations for seniors, such as the National Council on Aging or the AARP. Your local senior center might offer help as well.

For more information about erectile dysfunction, please click here.

Resources

Blue Cross Blue Shield of North Carolina

“Medicare Part C Medical Coverage Policy Penile Implants”

(Reviewed: July 12, 2017)

https://www.bluecrossnc.com/sites/default/files/document/attachment/services/public/pdfs/bluemedicare/medicalpolicy/penile_implants.pdf

Centers for Medicare and Medicaid Services

“Items and Services Not Covered Under Medicare”

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Items-and-Services-Not-Covered-Under-Medicare-Booklet-ICN906765.pdf

“Medicare Program - General Information”

(Page last modified: June 1, 2018)

https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html

GoodRx.com

“Muse Medicare Coverage”

https://www.goodrx.com/muse/medicare-coverage

Medicare.com 

(Note: Medicare.com is not the U.S. Government website for Medicare.  That website is www.Medicare.gov.)

Cross, Jory

“Does Medicare cover penile implants?”

(Updated: September 10, 2018)

https://medicare.com/coverage/does-medicare-cover-penile-implants/

Olmos, Mike

“What ‘Medically Necessary’ Means and How It Affects Your Medicare Coverage”

(Updated: September 16, 2018)

https://medicare.com/resources/what-medically-necessary-means-and-how-it-affects-your-medicare-coverage/

Medicare Interactive

“Drugs excluded from Part D coverage”

(https://www.medicareinteractive.org/get-answers/medicare-prescription-drug-coverage-part-d/medicare-part-d-coverage/drugs-excluded-from-part-d-coverage

National Council on Aging

“Medicare Part D Drug Plans: What They Must, May, and Cannot Cover”

(PDF. August 2017)

https://www.ncoa.org/wp-content/uploads/part-d-drug-coverage-rules.pdf

Pfizer

“Find Assistance That's Right for You”

https://www.pfizerrxpathways.com/

“Save 50% on brand-name VIAGRA for up to 12 prescriptions per year”

https://www.viagra.com/savings-offer

SexHealthMatters

“Self-Injection - Erectile Dysfunction”

https://www.sexhealthmatters.org/erectile-dysfunction/self-injection-erectile-dysfunction

WebMD

“Erectile Dysfunction: Penile Prosthesis”

(September 11, 2017)

https://www.webmd.com/erectile-dysfunction/guide/penile-prosthesis#1