Cialis Daily Is Advertised For BPH Treatment, Approved By The FDA, But Not Covered By Insurance. Why?

I am a 71 yr.. old Male and have been on several Meds, for BPH, I have also had Prostate Cancer abt. 10 yrs. ago, the side effects from those meds. keep me from taking them. The Cialis 5mg Daily work very well with no side effects. So now my free samples are running out and it is so very expensive to buy. Why do the Insurance Companies refuse to pay any part ? It is approved by the FDA for this treatment. It works very well.

  1. 11498 POINTS
    Jason Goldenzweig
    Co-Founder, TermInsuranceBrokers.com, Goldenzweig Financial Group, Las Vegas, Nevada
    It ultimately depends on what prescription drug plan you have. Not all drug plans are the same. The list of covered drugs (also known as a formulary for Medicare programs) will tell you whether your Cialis prescription will be covered. If it's listed as a covered drug, then you would only pay your share of the expense (deductible, copay, and/or coinsurance, etc.). If it's not a covered drug, then you would be responsible for 100% of the cost.

    It may simply be that the prescription drug plan you have does not cover this specific drug.\

    At age 71, I'm assuming you're on Medicare. If so, regardless of whether your drug coverage is under a Medicare Advantage plan or through a stand-alone Part D plan, you would not be able to make any changes to your drug coverage until the annual enrollment period (October 15 - December 7 of each year). During the annual enrollment period, you can evaluate your options to see which carrier's plan will cover this prescription.

    If you're covered under an employer plan, options may be limited, but if more than one option is available, I would recommend reviewing each of them to see which plan will be most suitable for your needs.

    If it's an individual poilcy, I recommend contacting the agent who placed the covered for you (that person would be the servicing agent for the program) or call your insurance carrier directly to find out if it should be a covered drug under your plan. If you have a group policy, then you would need to either contact the carrier directly or your human resources department should be able to put you in contact with the appropriate person.

    I hope the information is helpful - please let me know if I can be of further assistance. Thanks very much.
    Answered on April 22, 2015
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  2. 37376 POINTS
    David G. Pipes, CLU®, RICP®
    Business Development Officer, T.D. McNeil Insurance Services, Fresno, California
    Insurance companies try to identify the cost of every benefit that they offer. When a drug does not appear on the covered list there is insufficient demand for the drug or the expense outweighs the benefit. While everything is negotiable, inclusion of another drug does affect the cost and ultimately the premium that you pay.
    Answered on April 23, 2015
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  3. 5527 POINTS
    Marlin McKelvy
    President, Consumer Directed Benefit Solutions, Memphis, Tennessee
    Cialis coverage depends upon the prescription drug formulary used by a specific health insurance carrier and the medical necessity for that specific drug. Having lost a family member to prostate cancer I sympathize with your situation. Unfortunately, there has been a fair amount of abuse of using the diagnosis of BPH as a screen to really get it covered for use for its effects on erectile dysfunction, that's one problem you are faced with. Secondly, Cialis does have a number of side effects that can be problematic for men with other health issues. There are other treatments for BPH that don't have as many side effects so these are probably preferred by your insurance carrier. This is an issue where coverage for Cialis can vary greatly from insurance carrier to insurance carrier. It may also be a case where your physician has not made the case for medical necessity for your particular condition. It is not uncommon to have an initial prescription request declined in these dual use drug scenarios and it may require more extensive communication and submission of medical records by your physician to your insurance carrier's pharmacy management unit to request approval. But certainly a very strong case of medical necessity will have to be made to get a prescription for Cialis approved. Let's face it, they're not advertising it for it's effects on BPH, they're advertising it so 71 year old can act like a 21 year old again.
    Answered on May 11, 2015
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