Does SelectHealth Cover Viagra? A Complete Coverage Guide

What SelectHealth Is and Why Plan Type Matters

SelectHealth is a Utah-based health insurance company affiliated with Intermountain Health, offering commercial, Medicare Advantage, and Medicaid (Select Health Community Care) plans across Utah, Idaho, and Nevada. Coverage for erectile dysfunction medications like Viagra or generic sildenafil is not uniform. It varies by product line, employer group contract, and annual formulary updates.

The FDA approved sildenafil citrate (brand name Viagra) for erectile dysfunction in March 1998 [1]. Generic sildenafil entered the U.S. Market in December 2017 after Pfizer's key patent expired, and the FDA has since approved dozens of generic manufacturers [2]. That generic availability is the single biggest factor driving whether SelectHealth will cover an ED medication at a reasonable cost to you.

Commercial Plans

SelectHealth's commercial plans, sold through employers or the individual marketplace, use tiered drug formularies. Brand-name Viagra typically appears on Tier 3 (preferred brand) or Tier 4 (non-preferred brand), while generic sildenafil may sit on Tier 1 (generic) or Tier 2 depending on the plan year. The practical difference is significant. A Tier 4 copay can run $80 to $120 per fill, while a Tier 1 generic copay often falls between $5 and $20.

Medicare Advantage Plans

Medicare Part D, which SelectHealth administers through its Medicare Advantage products, has a specific restriction worth knowing. The Social Security Act historically excluded coverage for drugs used for "sexual or erectile dysfunction" unless the drug was also approved for another covered condition [3]. Sildenafil is FDA-approved under the brand name Revatio for pulmonary arterial hypertension (PAH), and at lower doses (20 mg tablets) it may be covered for that indication. Viagra at 25 mg, 50 mg, or 100 mg tablets for ED is generally excluded from Medicare Part D formularies.

Medicaid (Select Health Community Care)

Utah's Medicaid program, administered in part by SelectHealth under Select Health Community Care, follows Utah Medicaid fee schedules and preferred drug lists published by the Utah Department of Health and Human Services. Generic sildenafil may appear on the Utah Medicaid preferred drug list for PAH at the 20 mg dose. Coverage for ED as the primary diagnosis is typically not available under Medicaid in Utah.

How SelectHealth Formularies Work

A formulary is a list of covered drugs, organized into tiers that determine your cost-sharing. SelectHealth updates its formularies annually, typically effective January 1. Formulary changes mid-year can affect ongoing prescriptions with a 60-day notice requirement under ACA rules [4].

Checking Your Specific Formulary

The most reliable method is to use the SelectHealth drug search tool available through your member portal at selecthealth.org. You will need your plan ID number. Enter "sildenafil" rather than "Viagra" first, because generic results populate separately from brand-name entries. If your plan covers sildenafil, the tool will display the tier, any quantity limits, and whether prior authorization (PA) is required.

Quantity Limits

Most SelectHealth plans that do cover sildenafil apply a quantity limit. A common limit is 6 to 8 tablets per 30-day supply for the 50 mg or 100 mg strengths. The clinical rationale for this limit comes from FDA prescribing guidance, which recommends no more than one dose per 24-hour period [5]. If your physician prescribes a higher quantity, the pharmacy will flag a quantity limit edit, and a PA or override request will be needed.

Step Therapy Requirements

Some SelectHealth employer group plans require step therapy, meaning you must try and document failure on a less expensive agent before the plan covers a more expensive one. In practice for ED medications, this usually means trying generic sildenafil at an adequate dose (typically 50 mg or 100 mg) for at least 4 to 6 weeks before a branded agent like Stendra (avanafil) would be considered.

Prior Authorization for Viagra and Sildenafil

Prior authorization is a formal process in which your prescribing physician submits clinical documentation to SelectHealth for review before the plan agrees to cover a drug. For brand-name Viagra specifically, PA is required on most SelectHealth commercial plans.

What the PA Process Involves

Your physician typically completes a PA form that asks for:

• Diagnosis code (ICD-10 N52.x for erectile dysfunction)
• Clinical documentation of ED severity, ideally using a validated tool such as the International Index of Erectile Function (IIEF) questionnaire [6]
• Documentation of any contraindications to alternative agents
• Medication history showing prior trials of generics if step therapy applies

SelectHealth is required under federal law to respond to standard PA requests within 3 business days and to urgent PA requests within 24 hours [7].

Common Reasons PA Is Denied

The most frequent denial reasons include incomplete clinical documentation, failure to meet step therapy criteria, or prescribing a quantity that exceeds plan limits. A denial notice must include the specific reason and must inform you of your right to appeal.

Tips to Improve PA Approval Rates

A 2021 review in the Journal of Managed Care and Specialty Pharmacy found that PA denial rates for PDE5 inhibitors ranged from 12 to 34 percent across commercial insurers, and that complete initial submissions reduced denial rates by approximately 40 percent [8]. Providing the IIEF score, listing any comorbidities contributing to ED (such as type 2 diabetes or post-prostatectomy status), and documenting a generic sildenafil trial upfront all strengthen the submission.

Appealing a SelectHealth Coverage Denial

A denial is not always the final word. SelectHealth, like all ACA-compliant insurers, must offer both internal and external appeal processes.

Internal Appeal

File within 180 days of receiving the denial notice. Your physician should submit a letter of medical necessity with supporting clinical records. SelectHealth must respond within 30 days for prospective (future) requests and 60 days for retrospective (already-dispensed) requests.

Expedited Appeal

If waiting 30 days would seriously jeopardize your health, you or your physician can request an expedited appeal. SelectHealth must decide within 72 hours [9]. ED medications rarely qualify for expedited review unless there is a documented clinical urgency.

External Review

If your internal appeal is denied, you have the right to request an independent external review through the Utah Insurance Department. This review is conducted by an Independent Review Organization (IRO) not affiliated with SelectHealth. Federal regulations under the ACA require the insurer to abide by the IRO's decision [10].

Generic Sildenafil: The Most Practical Coverage Path

For most SelectHealth members, generic sildenafil is the clearest route to affordable, covered ED treatment. The clinical evidence for generic sildenafil is identical to that for brand-name Viagra because they share the same active molecule, the same pharmacokinetic profile, and equivalent bioavailability as established through FDA bioequivalence standards [11].

Clinical Efficacy Data

The original key trial data supporting sildenafil approval remains the benchmark. In Goldstein et al. (1998), published in the New England Journal of Medicine (N=532), sildenafil at 25 to 100 mg produced successful intercourse in 69 percent of attempts versus 22 percent for placebo (P<0.001) [12]. A 2014 Cochrane meta-analysis of 7 randomized controlled trials (N=751) confirmed that sildenafil improved IIEF erectile function domain scores by a mean of 6.4 points over placebo [13].

Dosing and Administration

The standard starting dose is sildenafil 50 mg taken 30 to 60 minutes before sexual activity. Dose may be adjusted to 25 mg or 100 mg based on response and tolerability. The drug should not be taken more than once in a 24-hour period [5]. Food, especially a high-fat meal, can delay absorption by up to 60 minutes and reduce peak plasma concentration by approximately 29 percent [14].

Drug Interactions That Affect Coverage Documentation

Sildenafil is contraindicated with nitrates (nitroglycerin, isosorbide mononitrate) due to the risk of severe hypotension [5]. It also requires dose adjustment with strong CYP3A4 inhibitors such as ritonavir, ketoconazole, and clarithromycin. When your physician documents these interactions in the PA, it can also support the case for a specific dose or formulation.

What SelectHealth Covers for Underlying ED Causes

ED is often a symptom of an underlying condition rather than a standalone diagnosis. SelectHealth generally covers evaluation and treatment of those underlying causes, which can be a useful clinical and financial approach.

Cardiovascular Risk and ED

The Massachusetts Male Aging Study demonstrated that ED affects approximately 52 percent of men aged 40 to 70, and that the severity correlates with cardiovascular risk factors including hypertension, dyslipidemia, and smoking [15]. A physician visit billed under cardiovascular risk assessment or hypertension management (ICD-10 I10, E11.x for diabetes) will typically be covered under standard medical benefits rather than requiring a pharmacy benefit approval.

Testosterone Deficiency

Hypogonadism is a recognized contributor to ED. SelectHealth commercial plans generally cover testosterone testing (total testosterone, free testosterone, LH, FSH) under the laboratory benefit when ordered with an appropriate diagnosis. If testosterone deficiency is confirmed (total testosterone <300 ng/dL per American Urological Association guidelines [16]), testosterone replacement therapy may be covered under the pharmacy benefit, and treating the underlying deficiency can improve ED without requiring a separate PDE5 inhibitor PA.

Psychogenic ED

Psychological contributors including anxiety, depression, and relationship stress account for a significant portion of ED cases, particularly in men under 40. SelectHealth mental health benefits, which must be offered at parity with medical benefits under the Mental Health Parity and Addiction Equity Act [17], may cover individual therapy or couples counseling when medically indicated.

Alternative ED Medications That May Have Better SelectHealth Coverage

If Viagra and generic sildenafil face PA hurdles on your plan, three other FDA-approved PDE5 inhibitors are worth discussing with your physician.

Tadalafil (Generic Cialis)

Generic tadalafil became available in the United States in 2018. It offers a longer duration of action (up to 36 hours versus 4 to 6 hours for sildenafil) and is also available as a daily low-dose option (2.5 mg or 5 mg). Because generic tadalafil is now widely available and inexpensive, SelectHealth plans frequently place it on Tier 1 or Tier 2. The FDA-approved doses for ED are 5 mg daily or 10 to 20 mg as needed [18].

Vardenafil (Generic Levitra)

Generic vardenafil is available and may appear on lower formulary tiers depending on the plan year. The standard dose is 10 mg taken 60 minutes before activity. A 2013 meta-analysis in the British Journal of Urology International (N=9,669 across 11 trials) found vardenafil improved IIEF erectile function domain scores by a mean of 7.1 points over placebo [19].

Avanafil (Stendra)

Avanafil remains brand-only as of 2025, meaning it almost always sits on a higher formulary tier. It has the fastest onset of the PDE5 inhibitors (as little as 15 minutes) and a shorter half-life, which some patients prefer. Coverage requires strong PA documentation and is unlikely to be approved before a generic trial.

The following decision framework can help you and your physician identify the fastest path to covered ED treatment under SelectHealth:

SelectHealth ED Coverage Decision Framework

1. Log into your SelectHealth member portal and search "sildenafil" in the drug formulary tool. Note the tier and any PA or quantity limit flags.
2. If sildenafil is Tier 1 or 2 with no PA required, ask your physician to prescribe generic sildenafil 50 mg with a quantity of 6 tablets per 30 days.
3. If PA is required, ensure your physician submits ICD-10 N52.x, IIEF score documentation, and any relevant comorbidities in the initial PA request.
4. If sildenafil PA is denied, search "tadalafil" in the formulary tool. Generic tadalafil may carry fewer restrictions.
5. If both are denied, file an internal appeal within 180 days with a letter of medical necessity that addresses the specific denial reason.
6. If the internal appeal is denied, request an external IRO review through the Utah Insurance Department within 4 months of the internal denial decision.

Cost Without Coverage: What You Will Actually Pay

If your SelectHealth plan does not cover Viagra and you choose not to pursue appeal or alternatives, knowing the real out-of-pocket field matters.

Brand-name Viagra retails at approximately $75 to $100 per tablet at major U.S. Pharmacies, making a monthly supply of 8 tablets roughly $600 to $800. Generic sildenafil without insurance typically costs $1 to $5 per tablet at major chains or through discount programs like GoodRx, making a monthly supply of 8 tablets $8 to $40.

The FDA requires that generic drugs meet bioequivalence standards demonstrating that the rate and extent of absorption do not differ significantly (within an 80 to 125 percent confidence interval) from the reference listed drug [11]. Choosing generic sildenafil over brand Viagra does not represent a clinical compromise for most patients.

Online pharmacies accredited by the National Association of Boards of Pharmacy (NABP) and telehealth platforms like HealthRX can support generic sildenafil prescriptions at competitive prices, often with same-day prescribing if you meet clinical criteria. The FDA maintains a list of approved online pharmacy programs at fda.gov [20].

What Your Physician Needs to Do Right Now

Coverage obstacles are usually solvable with complete documentation. Here is a concrete action list.

Ask your physician to:

• Use ICD-10 N52.9 (male erectile dysfunction, unspecified) or a more specific code if applicable (N52.01 for vasculogenic, N52.1 for psychogenic)
• Administer and document a formal IIEF-5 score (5 questions, scored 5 to 25; scores of 21 or below indicate some degree of ED) [6]
• Note any relevant comorbidities: type 2 diabetes, hypertension, hypogonadism, post-radical prostatectomy status
• Confirm there are no nitrate contraindications
• Submit a generic sildenafil prescription first to establish a trial record before requesting brand Viagra

The American Urological Association's 2018 guideline on erectile dysfunction states: "Phosphodiesterase type 5 inhibitors are recommended as first-line therapy for most patients with erectile dysfunction due to their efficacy, safety profile, and ease of use." [16] That guideline language is precisely the kind of clinical support that strengthens a PA submission or appeal letter.

The Endocrine Society's clinical practice guideline on male hypogonadism recommends evaluating all men with ED for hypogonadism before or alongside prescribing PDE5 inhibitors, because testosterone levels below 300 ng/dL independently predict reduced PDE5 inhibitor response [21].

If your SelectHealth plan is an employer-sponsored group plan, your HR benefits coordinator can also request a formulary exception review directly with SelectHealth's pharmacy benefits team, which sometimes bypasses the standard PA queue and reaches a formulary exceptions committee faster.