Does Health Net Cover Cialis?

What Is Cialis and Why Does Coverage Get Complicated?

Cialis (tadalafil) is an FDA-approved phosphodiesterase type 5 (PDE5) inhibitor with three separate indications: erectile dysfunction (ED), benign prostatic hyperplasia (BPH), and pulmonary arterial hypertension (PAH) [1]. The FDA granted tadalafil its ED approval in 2003 and added the BPH indication in 2011 [2].

Coverage is complicated for one reason: most commercial insurers classify ED drugs as "lifestyle medications" and exclude them from standard formularies by default. The same active molecule, however, is almost always covered for BPH or PAH because those diagnoses are not considered lifestyle conditions.

How PDE5 Inhibitors Work

Tadalafil blocks the PDE5 enzyme in smooth muscle cells, allowing cyclic guanosine monophosphate (cGMP) to accumulate. That accumulation relaxes vascular smooth muscle and increases blood flow to the corpus cavernosum. A 2007 Cochrane review of 24 randomized trials confirmed that tadalafil produces statistically significant improvements in the International Index of Erectile Function (IIEF) score versus placebo [3].

The Brand Versus Generic Distinction

Eli Lilly's patent on brand Cialis expired in September 2018. Generic tadalafil entered the U.S. Market shortly afterward, and the FDA maintains a current list of approved tadalafil generics from multiple manufacturers [4]. Because generics are bioequivalent by FDA definition, plans that do cover tadalafil almost always prefer the generic, placing it on Tier 2 while brand Cialis sits on Tier 4 or is excluded entirely.

How Health Net Formularies Are Structured

Health Net operates several distinct plan types: commercial HMO/PPO products sold in California, Arizona, and Oregon; Medicare Advantage plans; and Medi-Cal managed care plans. Each has its own formulary [5].

Commercial Plan Formulary Tiers

Health Net's commercial formularies typically use a five-tier structure:

• Tier 1, preferred generics, lowest copay (often $5, $15)
• Tier 2, non-preferred generics or preferred brands (often $30, $60)
• Tier 3, non-preferred brands (often $60, $100)
• Tier 4, specialty drugs (coinsurance of 20 to 30%)
• Tier 5 / excluded, drugs the plan does not cover at negotiated rates

Generic tadalafil for ED lands on Tier 2 or Tier 3 on most Health Net commercial formularies reviewed for plan year 2024, but the specific tier varies by plan. Brand Cialis is frequently excluded (Tier 5) or placed on Tier 4 with a non-preferred specialty copay.

Medicare Advantage Formulary Rules

Health Net's Medicare Advantage plans follow CMS Part D rules. CMS prohibits Part D plans from covering drugs used "for cosmetic purposes or to promote hair growth" but does not categorically exclude ED drugs [6]. CMS guidance issued in 2023 noted that Part D plans may cover tadalafil when prescribed for a medically accepted indication such as BPH [7]. If your diagnosis is BPH (ICD-10 N40.1), coverage is far more likely than if the primary diagnosis is ED (ICD-10 N52.9).

Medi-Cal Coverage

California's Medi-Cal fee-for-service program generally does not cover PDE5 inhibitors for ED but does cover tadalafil for PAH under the Medi-Cal Drug List [8]. Health Net's Medi-Cal managed care plans mirror this policy. Members with a PAH diagnosis should ask their prescriber to submit the claim under the correct diagnosis code and obtain a prior authorization through the managed care plan's pharmacy department.

Prior Authorization Requirements for Tadalafil on Health Net

Prior authorization (PA) is the most common barrier to tadalafil coverage. Health Net's standard PA criteria for tadalafil (when coverage is allowed at all) typically require the following:

Step Therapy Requirements

Step therapy means you must try and fail a first-line medication before the plan will approve a second-line agent. For ED, Health Net commonly requires:

1. Documentation that the member has a confirmed diagnosis of ED or BPH with ED symptoms.
2. A trial of at least one other PDE5 inhibitor (sildenafil is generic and lower-cost) for four to eight weeks at an adequate dose.
3. Attestation from the prescribing provider that sildenafil was ineffective or caused intolerance.

The American Urological Association (AUA) 2018 guideline on ED states: "PDE5 inhibitors are the preferred first-line pharmacological therapy for ED in most patients" and does not mandate one agent over another within the class [9]. That language gives prescribers some room to argue that a trial of any PDE5 inhibitor (including tadalafil) satisfies step therapy.

How to Submit a PA Request

Your prescriber submits the PA through Health Net's online portal or by fax. Required documentation generally includes:

• The ICD-10 diagnosis code (N52.9 for unspecified male erectile dysfunction, N40.1 for BPH with lower urinary tract symptoms)
• Clinical notes confirming the diagnosis and duration of symptoms
• Records of any prior medication trials
• The prescriber's National Provider Identifier (NPI)

Health Net must respond to a standard PA request within three business days under California law (for urgent requests, 72 hours or sooner) [10].

What Happens If Health Net Denies Coverage?

A denial is not the end. California members have specific appeal rights under Department of Managed Health Care (DMHC) regulations [11].

Internal Appeal

File a written appeal within 30 days of the denial notice. Include a letter of medical necessity from your urologist or primary care physician citing the AUA guideline language above and any peer-reviewed evidence supporting tadalafil specifically over sildenafil for your clinical situation.

Independent Medical Review

If the internal appeal fails, California law allows you to request an Independent Medical Review (IMR) through the DMHC at no cost to you. The DMHC's 2022 annual report noted that approximately 40% of IMR decisions resulted in plan overturns [11]. That figure is meaningful: four in ten members who pursue an IMR get the coverage reversed.

Expedited Review

If your condition is urgent (for example, severe BPH causing urinary retention risk), request an expedited review. Health Net must respond within 72 hours [10].

Cost Without Coverage: Real Numbers

If coverage is denied or you prefer to pay out of pocket, actual costs vary significantly by pharmacy and discount program.

Brand Cialis Pricing

Brand Cialis 20 mg (30 tablets) carries an average retail price of approximately $450 at major U.S. Pharmacy chains as of mid-2024. No manufacturer coupon program currently offsets this cost substantially for commercially insured patients, since the Eli Lilly savings card excludes members with insurance coverage for the drug.

Generic Tadalafil Pricing

Generic tadalafil 20 mg (30 tablets) costs approximately $20 to $35 at most pharmacies with a GoodRx or similar coupon. The FDA's approved generic drug database lists more than a dozen tadalafil manufacturers, creating genuine price competition [4]. Daily-dose tadalafil 5 mg (used for BPH or daily ED therapy) can be found for under $25 per 30-day supply at several national pharmacy chains with discount programs.

Telehealth and Compounding Options

Several telehealth platforms (including HealthRX) offer generic tadalafil prescriptions with pharmacy fulfillment at prices that frequently fall below $2 per dose. The FDA has not approved compounded tadalafil specifically, and compounding pharmacies operate under state pharmacy board oversight rather than FDA drug approval pathways [12]. Patients should confirm the compounding pharmacy holds valid state licensure and is a member of the Pharmacy Compounding Accreditation Board (PCAB).

Clinical Evidence Supporting Tadalafil Coverage

Payers that do cover tadalafil cite a substantial clinical evidence base. Understanding that evidence helps when writing an appeal letter.

Erectile Dysfunction Trials

The key registration trials for tadalafil included Study 35 (N=216) and Study 37 (N=280), published in the European Urology literature. Across a pooled analysis of 14 tadalafil phase III trials (N=2,102), tadalafil 20 mg on-demand produced a mean IIEF-EF domain score improvement of 8.6 points versus 1.8 points for placebo [13]. That difference of 6.8 points exceeds the minimum clinically important difference of 4 points established for the IIEF-EF scale [14].

BPH and Lower Urinary Tract Symptoms

A multicenter randomized controlled trial (N=1,058) published in the Journal of Urology showed that tadalafil 5 mg daily reduced International Prostate Symptom Score (IPSS) by 4.9 points versus 2.5 points for placebo after 12 weeks (P<0.001) [15]. The FDA approved the 5 mg daily dose specifically for BPH in 2011 based on this evidence [2].

Cardiovascular Safety

The Princeton Consensus III recommendations (2012) stratify cardiovascular risk before prescribing PDE5 inhibitors [16]. Most men with stable cardiovascular disease fall into the low-risk category and may safely use tadalafil. A 2014 meta-analysis of 14 randomized trials (N=7,115) published in the Journal of Sexual Medicine found no significant increase in major adverse cardiovascular events with PDE5 inhibitor use versus placebo [17].

A Practical Step-by-Step Coverage Checklist for Health Net Members

Use this sequence to maximize your chance of getting tadalafil covered:

Step 1: Confirm Your Plan's Formulary Status

Log into healthnet.com, manage to "Pharmacy," and use the drug search tool. Enter "tadalafil" (not "Cialis"). Note the tier, any quantity limits, and whether a PA is required. Screenshot this page for your records.

Step 2: Confirm Your Diagnosis Code

Ask your prescriber which ICD-10 code will appear on the prescription. For BPH with lower urinary tract symptoms, N40.1 triggers different (often more favorable) coverage rules than N52.9 (ED). Both may be valid if you have both conditions.

Step 3: Try Sildenafil First If Required by Step Therapy

Generic sildenafil 100 mg costs approximately $10 to $20 for a 30-count with a discount coupon. Using it for four weeks satisfies step therapy and gives your prescriber documented grounds to request tadalafil if sildenafil is inadequate or poorly tolerated. Sildenafil's shorter duration of action (four to six hours) versus tadalafil's 36-hour window is a clinically meaningful distinction [18].

Step 4: Have Your Prescriber Submit a PA with a Strong Letter of Necessity

The letter should reference the AUA 2018 guideline, cite your specific IIEF score or IPSS score, and explain why tadalafil specifically (rather than another PDE5 inhibitor) is indicated. Quantified symptom scores carry more weight than subjective statements in PA reviews.

Step 5: Appeal If Denied

File the internal appeal within 30 days. Attach peer-reviewed references (the trials cited in this article are all publicly accessible on PubMed). If the internal appeal fails, file an IMR with the DMHC online at dmhc.ca.gov.

Step 6: Use a Discount Coupon as a Bridge

While appeals are pending, fill a 30-day supply of generic tadalafil using a GoodRx or RxSaver coupon. You cannot use a discount coupon and your insurance simultaneously, but you can use a coupon during any gap in coverage.

Special Populations and Coverage Nuances

Diabetes-Related ED

Men with type 2 diabetes have a prevalence of ED approaching 50%, according to a 2022 meta-analysis of 145 studies (N=88,577) published in Diabetic Medicine [19]. Health Net commercial plans that follow ADA Clinical Practice Recommendations may be more receptive to PA approvals for tadalafil in diabetic members because ED in this population is a documented complication rather than a lifestyle consideration. Including the diabetes diagnosis (E11.65 for type 2 diabetes with hyperglycemia) in the PA documentation strengthens the medical necessity argument.

Post-Prostatectomy ED

Nerve-sparing radical prostatectomy preserves erectile function in roughly 40% to 70% of men at two years, depending on surgeon volume and nerve preservation technique, according to data from the MUSIC collaborative [20]. Men with post-prostatectomy ED have a clear medical etiology. Health Net Medicare Advantage plans may recognize this as a covered post-surgical complication. Document the surgical history explicitly in the PA request.

Pulmonary Arterial Hypertension

For PAH, tadalafil is marketed as Adcirca (40 mg daily) rather than Cialis. Health Net formularies almost universally cover Adcirca for PAH because it is not a lifestyle drug. The PHIRST trial (N=405) showed that tadalafil 40 mg daily increased six-minute walk distance by 33 meters versus placebo (P<0.001) at 16 weeks [21]. If your prescriber is managing both PAH and ED with tadalafil, the PAH indication alone may justify formulary coverage.