Cialis is a medication used to relieve impotence and symptoms of benign prostatic hyperplasia. It is one of the most popular medications that has really helped many men to regain their sexual life and better lives overall. But the question is, does Cialis have insurance coverage? In this article, we will discuss the insurance coverage for Cialis and the reasons behind it.
The first thing you need to understand is how insurance coverage works. Insurance companies list the medications they cover, which is called a formulary. This formulary refers to a list of medicines the insurance company has committed to providing for its customers. The formulary is sometimes segmented into tiers and the levels in each tier represent the level of coverage and cost for the drug. Drugs in the lower range are usually cheaper and more comprehensive whereas drugs in the upper range are more costly and less comprehensive.
Cialis is in the upper tier of most insurance formularies, which means it’s more expensive and less covered. This is because Cialis is a prescription brand and there’s a generic version called tadalafil, which tends to cost less. Generic drugs are generally more affordable than brand-name drugs in the eyes of insurance companies. That doesn’t mean that Cialis never goes on insurance.
One of the major factors in determining whether Cialis is covered by insurance or not is the reason for which it is prescribed. Unlike ED and BPH, Cialis is prescribed for both conditions as stated earlier. Insurance companies are more likely to reimburse Cialis for treating BPH because it’s a medical problem, not a lifestyle condition. Conversely, ED can be viewed as a life-style condition, and so insurers may hesitate to reimburse Cialis for this.
Insurance coverage for Cialis also depends on an individual’s insurance policy.
Insurance Plans and Medication Coverage
… The heart of this insurance coverage is the formulary, a key component in health insurance. A formulary is a list of medications in a specific plan. Drugs on these formularies, too, can be divided into tiers by cost.
Tier 1 would thus include the most affordable medicines, e.g., generic drugs, and those that have the lowest out-of-pocket costs for the patient.
Tier 3 or higher, including generic non-formulary or brand name drugs. Drugs for Tier 3 include, but are not limited to, Cialis. These levels for Cialis largely dictate the patient’s out-of-pocket costs. Because Cialis is brand-name and somewhat expensive, it falls in the top levels of lists, and can often charge patients much more than their insurance will reimburse them for.
Private Insurance Plans
If you do have private insurance (such as an employer’s benefit), Cialis coverage can be extremely patchy. However, some private insurance policies will heavily cover the medication and others may require a patient to pay more for the drug. These are some things that might affect this coverage:
Actual insurance plan details. Each and every insurance plan has its own formulary and tiering system.
The drug of choice for the prescriber, since physicians might have alternatives that would be more favorably covered by insurance.
Individual Patients who do have private insurance should check to see if their plan includes a Cialis formulary and determine how much coverage they receive and the likely out-of-pocket expenses associated with receiving Cialis.
Public Insurance Plans
The same goes for public insurance plans, like Medicare and Medicaid, that make Cialis a significant exception. These programs come in different coverage types and have rules and regulations for eligibility and medication costs.
While Medicare did provide prescription drug coverage under Part D plans, it would typically include Cialis in such plans. The patient would simply be asked to pay a co-pay, which is typically a percentage of the cost of the actual medication. Different plans will have different percentages, so even at Medicare, there will be some difference in the cost.
Medicaid: For state programs, Medicaid may provide Cialis more fully. The coverage for Fais in some states may be universal, with the eligible patients receiving the drug cheaply or free of charge. Those Medicaid benefits would, of course, come with restrictions as to who qualifies, and as to whether you could prescribe Cialis, for instance.
Implications for Patients:
Individual insurance coverage can affect patients in very specific ways. Cialis can be expensive for patients who do not have much or no coverage, and this limits the accessibility of the drug. Patients might even be forced to accept less expensive treatments that are less effective or contain similar side-effects. Furthermore, patients might become more likely to quit or postpone treatment owing to the cost, resulting in worsening symptoms and diminished quality of life.
Lastly, even if Cialis is covered by your insurance, the drug might require some out of pocket expenses. These may include copayments, deductibles, or coinsurance, as well, depending on the coverage that an individual has. It is always best to consult with your insurance company about how much Cialis will cost on your policy.
Ultimately, whether Cialis is insured or not is neither a yes nor a no because most addictions enter the picture with this in mind. Insurance coverage for Cialis can be determined depending on several aspects including the use of the prescription, the health insurance of the person, insurance company’s requirement, and many more. Cialis isn’t a prescription drug, but there are ways you can cut costs such as taking generic versions or some type of financial assistance program. Make sure you check with your doctor and insurer to get an idea of what is available to you and what would work best for you.
