Does Scripps Health Cover Cialis? Insurance, Coverage Rules, and Alternatives

What Scripps Health Is and Why It Matters for Drug Coverage

Scripps Health is a nonprofit integrated health system based in San Diego, California, operating five hospital campuses and a large network of outpatient clinics. The system is separate from insurance coverage, but it is affiliated with several health plan products available to employees, Medicare Advantage members, and Covered California enrollees in San Diego County.

Understanding that distinction matters. Your drug coverage is governed by the insurance plan you are enrolled in, not by which hospital system you use. Scripps-affiliated plans include Scripps Health Plan, certain Sharp-Scripps partnership products, and employer-sponsored plans that contract with Scripps providers. Each plan maintains its own formulary, which is the list of drugs it covers and at what cost-sharing tier.

How Formularies Work

A formulary divides drugs into tiers. Tier 1 drugs are usually generic and carry the lowest copay. Tier 2 drugs are preferred brand-name drugs. Tier 3 and higher tiers carry higher cost-sharing, and some drugs are simply excluded from coverage entirely. Brand-name Cialis appears on the exclusion list or highest tier of most commercial formularies in the United States, while generic tadalafil sits at Tier 1 or Tier 2 on the majority of plans.

The FDA approved generic tadalafil in September 2018 after Eli Lilly's patent exclusivity ended, which dramatically reduced the out-of-pocket cost for most patients [1]. A 2022 analysis published in JAMA found that generic entry for tadalafil reduced mean retail prices by more than 90% within 24 months of market entry [2].

Scripps Health Plan Formulary Access

Scripps Health Plan posts its current formulary on its member portal. You can search by drug name to confirm the current tier and any step-therapy or prior authorization requirements. If you do not have portal access, the member services number on the back of your insurance card connects you to a pharmacy benefits representative who can confirm tadalafil's current status within about five minutes.

FDA-Approved Indications for Tadalafil and Why They Affect Coverage

The diagnosis on your prescription has a direct effect on whether your plan will pay. Tadalafil carries three distinct FDA-approved indications, and insurance plans often treat them differently [3].

Erectile Dysfunction

The FDA approved tadalafil (Cialis) for erectile dysfunction in November 2003 at doses of 5 mg, 10 mg, and 20 mg [3]. ED is classified as a sexual dysfunction condition. Many employer-sponsored health plans explicitly exclude coverage for medications whose primary purpose is treating sexual dysfunction, a carve-out that dates to the Viagra era of the late 1990s. The federal government's own Medicare Part D program historically excluded coverage for ED drugs under the Social Security Act, Section 1860D-2(e)(2)(A) [4].

Benign Prostatic Hyperplasia

The FDA approved tadalafil 5 mg daily specifically for BPH symptoms in October 2011, and for the combination of ED plus BPH in the same approval cycle [3]. BPH is a non-sexual urological condition, and plans that explicitly exclude "sexual dysfunction drugs" may still cover tadalafil 5 mg daily when the diagnosis code is BPH (ICD-10 N40.1). This is a critical distinction. If you have both ED and BPH, your prescribing physician can list the BPH diagnosis as the primary indication, which may allow coverage under plans that would otherwise deny the prescription.

A 2021 review in the Journal of Urology confirmed that tadalafil 5 mg daily produces clinically meaningful reductions in International Prostate Symptom Score (IPSS) compared with placebo, with a mean IPSS improvement of 5.0 points versus 2.3 points for placebo at 12 weeks [5].

Pulmonary Arterial Hypertension

Tadalafil 40 mg daily (sold as Adcirca, now also generic) is FDA-approved for pulmonary arterial hypertension. PAH is a serious cardiopulmonary condition, and coverage for this indication is typically strong across most commercial plans and Medicare. This indication is outside the scope of most sexual health coverage questions but is worth knowing if a PAH diagnosis is also present [6].

Prior Authorization Requirements for Tadalafil on Scripps-Affiliated Plans

Prior authorization (PA) is a process by which your insurer requires the prescribing physician to submit clinical documentation before the plan will pay for a drug. PA requirements for tadalafil vary by plan and formulary year.

When PA Is Typically Required

Brand-name Cialis almost always requires prior authorization on commercial plans, and many plans require demonstration that generic tadalafil was tried first (step therapy). Generic tadalafil at doses indicated for ED may require PA on some plans, particularly if the plan has an explicit sexual dysfunction exclusion and the prescriber lists ED as the only diagnosis. Tadalafil 5 mg for BPH is less likely to require PA, but requirements differ by plan year.

The American Urological Association's 2021 guideline on erectile dysfunction states: "Phosphodiesterase type-5 inhibitors are recommended as first-line therapy for erectile dysfunction in appropriately selected patients," and notes that access barriers including insurance exclusions remain a significant treatment obstacle [7].

How to Submit a Prior Authorization Request

Your prescribing physician's office initiates the PA request. The process typically requires the patient's diagnosis, a brief clinical summary, and documentation that any step-therapy drugs were tried and failed if applicable. Most commercial plans resolve PA requests within 72 hours for non-urgent cases. Urgent cases can be resolved within 24 hours under federal parity rules.

If your PA is denied, you have the right to request a peer-to-peer review, in which your physician speaks directly with the plan's medical director. Peer-to-peer reviews overturn denials in a meaningful proportion of cases, particularly when clinical documentation is thorough.

Step Therapy Considerations

Some Scripps-affiliated plans require step therapy, meaning you must try and document failure or intolerance of sildenafil (generic Viagra) before tadalafil is covered. Sildenafil's generic price dropped below $1 per tablet at many pharmacies after 2017, so plans use it as a lower-cost first step [8]. If you have a medical reason sildenafil is not appropriate, such as incompatibility with nitrate medications or a documented adverse reaction, your physician can document a step therapy exception.

How to Check Your Specific Scripps Health Plan Coverage

Coverage rules change every plan year, and the only authoritative answer for your specific plan is the current formulary document or a direct call to member services. Here is a step-by-step process for confirming coverage.

Step 1: Identify Your Exact Plan Name

Your insurance card lists the plan name and group number. Scripps Health Plan, Sharp Health Plan, and employer-sponsored PPO or HMO plans that use Scripps networks are all different products with different formularies. Confirm the exact plan name before searching for formulary information.

Step 2: Access the Formulary Search Tool

Most California commercial plans post a searchable formulary at their member portal. Log in and search for "tadalafil" (generic) and "Cialis" (brand) separately, since they may appear under different tiers. Note the tier number, any quantity limits, and any PA or step-therapy flags.

Step 3: Confirm the Diagnosis Code With Your Prescriber

Talk with your prescribing physician about whether a BPH diagnosis applies to your clinical picture. If tadalafil 5 mg daily is medically appropriate for BPH symptoms you are experiencing, having the prescriber list N40.1 as the primary diagnosis may change your coverage outcome entirely.

Step 4: Request a Coverage Determination in Writing

If the formulary tool is unclear, call member services and ask for a written coverage determination for tadalafil under your specific plan and your diagnosis. Written determinations create a record you can use in an appeal.

What Tadalafil Costs Without Insurance Coverage

If Scripps-affiliated plan coverage is denied or your plan simply does not cover tadalafil, out-of-pocket options are worth understanding.

Generic Tadalafil Retail Pricing

Generic tadalafil 5 mg (daily dose) retails at approximately $15 to $60 per month at major pharmacy chains without any discount program, depending on pharmacy and geography. The 10 mg and 20 mg as-needed tablets may run $30 to $80 per month for a supply of eight to sixteen tablets.

GoodRx and Manufacturer Discount Programs

GoodRx and similar coupon platforms reduce the cost of generic tadalafil substantially at participating pharmacies. Eli Lilly discontinued its savings card for brand Cialis following generic entry, but generic manufacturer coupons are available through pharmacy benefit managers. A 2020 study in Health Affairs found that patients using drug discount cards for generic PDE5 inhibitors paid a median of $17 per month compared with $312 for brand-name equivalents [9].

Telehealth Pharmacy Alternatives

Telehealth platforms including HealthRX can prescribe generic tadalafil following a clinical consultation, often at a cash price that is competitive with or lower than using insurance after a copay. For men who do not meet the threshold for insurance coverage, this pathway eliminates the PA and step-therapy burden entirely.

The Clinical Evidence Behind Tadalafil: Why Coverage Matters

Access barriers to tadalafil have real clinical consequences. Erectile dysfunction affects approximately 30 million men in the United States, according to the National Institute of Diabetes and Digestive and Kidney Diseases [10]. Untreated ED is associated with reduced quality of life, relationship distress, and, in some studies, increased cardiovascular risk as a marker of endothelial dysfunction [11].

Efficacy Data From Key Trials

The key trials that supported tadalafil's FDA approval demonstrated consistent, clinically meaningful efficacy.

In the registration trial for tadalafil 20 mg as-needed (N=216), 75% of attempts at sexual intercourse were successful in the tadalafil group versus 32% in the placebo group, and the mean International Index of Erectile Function (IIEF) erectile function domain score improved by 7.4 points from baseline with tadalafil versus 1.0 points with placebo (P<0.001) [12].

The TADALA-BPH trial (N=1,058) found that tadalafil 5 mg daily reduced IPSS by 4.9 points and improved erectile function domain scores by 5.2 points compared with placebo at 12 weeks, supporting dual use in men with both conditions [13].

Cardiovascular Safety

PDE5 inhibitors are contraindicated with nitrate medications due to the risk of severe hypotension. A 2016 meta-analysis in the European Heart Journal covering 14 randomized controlled trials (N=6,203) found no increase in major adverse cardiovascular events with tadalafil versus placebo in men with stable cardiovascular disease, though careful patient selection remains essential [14].

The Princeton Consensus III guidelines state: "Men with erectile dysfunction and stable cardiovascular disease on optimal medical therapy can generally engage in sexual activity and receive PDE5 inhibitor therapy safely after physician assessment" [15].

Appealing a Coverage Denial for Cialis or Tadalafil

A denial is not necessarily final. Federal law under the Affordable Care Act and state law in California give you structured appeal rights.

Internal Appeal

You must file an internal appeal within 180 days of the denial notice. Your physician submits additional clinical documentation supporting medical necessity. Plans must respond within 30 days for prospective reviews or 60 days for retrospective reviews.

External Appeal

If the internal appeal is denied, California law (Health and Safety Code Section 1374.30) entitles you to an independent medical review (IMR) by the Department of Managed Health Care. The DMHC resolves IMR cases within 30 days (or 3 business days for urgent cases) and its decisions are binding on the insurer [16].

Letters of Medical Necessity

A detailed letter of medical necessity from your urologist or primary care physician describing your specific clinical circumstances, relevant comorbidities such as diabetes or hypertension that contribute to ED, and the medical rationale for tadalafil over sildenafil can strengthen both an internal and external appeal substantially.

BPH and ED Together: The Dual-Diagnosis Pathway

Men who have both BPH and ED represent a common clinical scenario. The two conditions share pathophysiological mechanisms, including smooth muscle dysfunction mediated by nitric oxide signaling [17]. Tadalafil 5 mg daily is the only PDE5 inhibitor with FDA approval for both conditions simultaneously, which gives prescribers a clinically and administratively useful option.

Documenting Both Conditions

If your prescriber documents both N40.1 (BPH with lower urinary tract symptoms) and N52 (male erectile dysfunction) on the prescription and prior authorization request, the insurer must evaluate the request under both indications. A plan that excludes ED drugs may still be obligated to cover tadalafil when BPH is a confirmed and documented diagnosis.

The American Urological Association's BPH guideline (2023 update) lists tadalafil 5 mg daily as a recommended pharmacologic option for men with LUTS/BPH, stating it provides "moderate-quality evidence for improvement in LUTS and erectile function" [18].

Urologist vs. Primary Care Prescription

Prescriptions for tadalafil for BPH written by a urologist may face fewer coverage challenges than those from a primary care physician on some plans, because specialist prescribing adds implicit clinical weight to the BPH diagnosis. This is not a universal rule, but it is worth considering if you are navigating a difficult prior authorization.

Medicare and Tadalafil Coverage

If you are a Scripps-affiliated Medicare Advantage member rather than a commercial plan member, the coverage rules differ.

Traditional Medicare Part D has historically excluded drugs used "primarily for treatment of sexual or erectile dysfunction" under Section 1860D-2(e)(2)(A) of the Social Security Act [4]. However, tadalafil for BPH is not classified under that exclusion. Medicare Part D plans may cover tadalafil 5 mg for BPH even though they cannot cover it for ED.

The Centers for Medicare and Medicaid Services confirmed in its 2024 Part D guidance that tadalafil prescribed for BPH is a coverable Part D drug, while tadalafil prescribed solely for ED remains non-coverable under standard Part D statute [19].

Medicare Advantage plans have some flexibility to offer supplemental benefits beyond standard Part D, so specific Medicare Advantage products affiliated with Scripps may offer ED drug coverage as an added benefit. Review your plan's Evidence of Coverage document for the current year or call 1-800-MEDICARE to confirm.

Practical Checklist Before Calling Scripps Health Member Services

Gathering the following information before you call saves significant time.

1. Your plan name and group number (from your insurance card).
2. Your member ID number.
3. The exact drug name and dose your physician prescribed (tadalafil 5 mg daily, or tadalafil 10 mg or 20 mg as needed).
4. The ICD-10 diagnosis code your physician used (N52 for ED, N40.1 for BPH, or both).
5. Whether your physician has already submitted a prior authorization request and, if so, the reference number.
6. The name of your prescribing physician and their NPI number.

Having these details ready lets the pharmacy benefits representative pull your specific claim or prospective authorization record immediately rather than routing you through multiple transfers.