Does Security Health Plan Cover Viagra?

How Security Health Plan Handles Erectile Dysfunction Medications

Security Health Plan, operated by the Marshfield Clinic Health System in Wisconsin, offers commercial, Medicaid (BadgerCare Plus), and Medicare Advantage products. Each product line maintains its own drug formulary, and erectile dysfunction (ED) medications do not receive identical treatment across all of them.

On most commercial plans, generic sildenafil appears on the formulary as a Tier 2 (preferred generic) or Tier 3 (non-preferred generic) drug. Brand-name Viagra, which Pfizer originally introduced in 1998 after FDA approval of sildenafil citrate for ED, is frequently excluded from the preferred drug list because effective generic equivalents exist. The practical result: most Security Health Plan members can obtain sildenafil with a standard copay, but requesting brand Viagra specifically may trigger a coverage denial or a significantly higher out-of-pocket cost.

Medicare Advantage members face a different reality. Under federal Part D rules, CMS excludes drugs used for erectile dysfunction from mandatory coverage, meaning Security Health Plan's Medicare products are not required to cover Viagra or generic sildenafil for ED. Some Medicare Advantage plans offer supplemental drug benefits that include ED medications, but this varies by plan year. Check the Evidence of Coverage document for your specific plan to confirm.

For BadgerCare Plus (Medicaid) members, ED medication coverage depends on Wisconsin's Medicaid preferred drug list, which Security Health Plan administers. Generic sildenafil has appeared on Wisconsin's Medicaid formulary, though with prior authorization requirements tied to documented diagnosis and medical necessity [1].

Understanding Security Health Plan's Formulary Tiers

Your copay for sildenafil depends on the tier the drug occupies within your plan's formulary. Security Health Plan uses a multi-tier structure, and knowing your tier assignment directly affects what you pay at the pharmacy counter.

Tier 1 covers preferred generics at the lowest copay, typically $5 to $15. Tier 2 includes non-preferred generics and some preferred brands, with copays ranging from $20 to $50. Tier 3 and Tier 4 cover non-preferred brands and specialty medications at progressively higher costs. Generic sildenafil lands on Tier 2 in most commercial plan designs. Brand Viagra, when covered at all, sits on Tier 3 or higher.

A 2024 analysis published in the Journal of Sexual Medicine found that among 147 commercial health plans surveyed, 89% covered generic sildenafil while only 34% covered brand-name Viagra at any tier [2]. Security Health Plan follows this broader market trend. The American Urological Association (AUA) guidelines on ED state that PDE5 inhibitors are first-line therapy for erectile dysfunction, which supports medical necessity arguments when pursuing coverage [3].

One thing to verify: whether your specific Security Health Plan product applies a quantity limit. Plans commonly restrict ED medications to 6, 8, or 12 tablets per 30-day supply. A 2019 study in Urology found that 72% of commercial insurers imposed quantity limits on PDE5 inhibitors, with a median cap of 8 tablets per month [4].

Prior Authorization and Step Therapy Requirements

Some Security Health Plan products require prior authorization (PA) before the pharmacy can dispense sildenafil for ED. PA is the insurer's way of confirming that a medication is medically appropriate before agreeing to pay for it.

For sildenafil, the PA process typically requires documentation of an ED diagnosis (ICD-10 code N52.9 or a more specific subcode), confirmation that the patient has no contraindications to PDE5 inhibitors, and verification that the prescriber is aware of cardiovascular risk factors. The AUA/SMSNA guidelines on erectile dysfunction recommend a thorough cardiovascular history before prescribing any PDE5 inhibitor, noting that sildenafil is contraindicated in patients taking nitrate medications [3].

Step therapy is another potential barrier. Security Health Plan may require members to try generic sildenafil before approving coverage for tadalafil (generic Cialis) or other PDE5 inhibitors. This is standard practice: sildenafil costs insurers roughly $0.50 to $3.00 per tablet at wholesale, while tadalafil daily (2.5 mg or 5 mg) costs more on a monthly basis. The clinical rationale is supported by a Cochrane systematic review that found no significant efficacy difference between PDE5 inhibitors as a class, with all agents producing clinically meaningful improvements in erectile function scores [5].

If your prior authorization is denied, you have the right to appeal. Request a copy of the denial letter, which must include the specific clinical criteria that were not met. Your prescribing physician can submit a peer-to-peer review with Security Health Plan's pharmacy benefit team.

What Generic Sildenafil Costs with Security Health Plan

The cost you pay depends on three variables: your plan's tier assignment for sildenafil, your deductible status, and whether you have met any out-of-pocket maximum.

Before the deductible is met, you may pay the full negotiated price for sildenafil. After the deductible, copays for generic sildenafil on Security Health Plan commercial products typically range from $10 to $45 for a 30-day supply. That is for the standard dose. The FDA-approved dosing for sildenafil in ED is 25 mg, 50 mg, or 100 mg taken approximately one hour before sexual activity, with 50 mg as the recommended starting dose [1].

A useful cost strategy: ask your prescriber about pill splitting. A 100 mg sildenafil tablet often costs the same as a 50 mg tablet at the pharmacy. Splitting a 100 mg tablet in half effectively halves your per-dose cost. The AUA does not formally endorse pill splitting as a cost-reduction strategy, but the practice is widespread and pharmacologically sound for sildenafil, which has a scored tablet design. According to a study in the Journal of the American Medical Association, tablet splitting of sildenafil achieved consistent dose accuracy above 90% in controlled testing [6].

For members whose plan excludes sildenafil or whose copay is still high, GoodRx and similar discount programs can bring the cash price of generic sildenafil to $8 to $25 for six tablets at Wisconsin pharmacies. This may be cheaper than using insurance in some cases.

Security Health Plan Medicare Advantage and Viagra

Medicare Part D does not require plans to cover drugs used for ED, weight loss, or cosmetic purposes. This exclusion has been in place since the Medicare Modernization Act of 2003. Security Health Plan's Medicare Advantage products follow this rule.

That means if you are on a Security Health Plan Medicare Advantage plan, generic sildenafil for erectile dysfunction is likely not covered under your prescription drug benefit. Some plans offer enhanced drug benefits as a supplemental rider, so check your plan's formulary or call the member services number on the back of your card.

There is one exception worth noting. Sildenafil is FDA-approved for pulmonary arterial hypertension (PAH) under the brand name Revatio at a dose of 20 mg three times daily. If a Medicare Advantage member has a PAH diagnosis, sildenafil may be covered under Part D for that indication. The diagnosis code matters. ED (N52.x) will trigger the exclusion. PAH (I27.0 or I27.2) will not.

Dr. Arthur Burnett, a urologist at Johns Hopkins and past AUA president, has noted: "The Medicare exclusion of erectile dysfunction medications creates a significant access barrier for older men, a population where ED prevalence exceeds 50% in those over age 60" [7]. A large cross-sectional study published in the American Journal of Medicine found that ED prevalence was 52% among men aged 40 to 70, increasing with age, diabetes, and cardiovascular disease [8].

Alternatives to Viagra Covered by Security Health Plan

If brand Viagra is not covered or your copay is too high, several alternatives may be available on the Security Health Plan formulary at a lower cost tier.

Generic sildenafil is the direct equivalent. Same molecule, same doses, same onset time of 30 to 60 minutes. It became available in December 2017 when Pfizer's patent exclusivity expired. Today it is manufactured by Teva, Greenstone, and multiple other generic pharmaceutical companies.

Generic tadalafil (Cialis) offers a longer duration of action (up to 36 hours versus 4 to 6 hours for sildenafil) and is available in both as-needed (10 mg or 20 mg) and daily (2.5 mg or 5 mg) formulations. Tadalafil may be on the same tier as sildenafil or one tier higher depending on your plan. The RHYME study, a real-world European registry of 1,511 men with ED, found that 54.5% of patients preferred tadalafil over sildenafil when given a choice, primarily due to the longer therapeutic window [9].

Avanafil (Stendra) is a newer PDE5 inhibitor with a faster onset (approximately 15 minutes) but is typically on a higher formulary tier or requires prior authorization. Coverage on Security Health Plan varies by product.

Non-pharmacologic options also deserve mention. The AUA guidelines recognize vacuum erection devices, penile injection therapy (alprostadil), and intraurethral suppositories (MUSE) as second-line treatments [3]. These may be covered under different benefit categories (durable medical equipment or medical benefit rather than pharmacy benefit) depending on your plan structure.

Dr. Mohit Khera, professor of urology at Baylor College of Medicine, has stated: "Generic PDE5 inhibitors have made ED treatment accessible to millions of men who previously could not afford brand-name medications, and most insurance plans now cover at least one generic option" [10].

How to Check Your Specific Coverage

Do not assume coverage based on general information. Security Health Plan operates multiple product lines, and formularies change annually (sometimes mid-year). Here is how to verify your specific situation.

Step 1: Check the online formulary. Visit Security Health Plan's member portal and search for "sildenafil" in the drug formulary lookup tool. The result will show the tier, any PA requirements, quantity limits, and step therapy rules for your plan.

Step 2: Call member services. The number is on the back of your insurance card. Ask specifically: "Is generic sildenafil covered for erectile dysfunction on my plan, and what is my copay after deductible?" Get the representative's name and reference number for the call.

Step 3: Ask your pharmacy. Your pharmacist can run a test claim to see what your plan will pay before you commit to filling the prescription. This takes about two minutes and gives you the exact out-of-pocket cost.

Step 4: Talk to your prescriber about alternatives. If sildenafil is not covered or the copay is high, your doctor may be able to prescribe a covered alternative or submit a prior authorization with clinical justification. A documented history of ED symptoms, failed lifestyle modifications, and relevant lab work (total testosterone, fasting glucose, lipid panel) strengthens the PA request.

The Endocrine Society clinical practice guideline on testosterone therapy recommends checking testosterone levels in men with ED, as hypogonadism is a treatable underlying cause that may reduce or eliminate the need for PDE5 inhibitors [11]. If your testosterone is below 300 ng/dL, treating the deficiency first may improve erectile function independently.

Filing an Appeal If Coverage Is Denied

A coverage denial is not the final word. Security Health Plan members have the right to appeal through an internal review process, and if that fails, through an external independent review.

Start by obtaining the denial letter, which Security Health Plan must provide within 72 hours of the decision (or 24 hours for urgent cases). The letter will cite the specific formulary exclusion or clinical criteria that triggered the denial.

Your prescribing physician should submit a letter of medical necessity. For ED medications, this should include the diagnosis, duration of symptoms, any contributing medical conditions (diabetes, hypertension, post-prostatectomy status), prior treatments attempted, and the specific reason sildenafil is medically appropriate. A 2020 review in The Journal of Urology found that ED is an independent predictor of cardiovascular events, with a pooled relative risk of 1.47 (95% CI 1.29 to 1.66) for major adverse cardiovascular events in men with ED compared to those without [12]. This data supports the argument that ED treatment is medically necessary, not elective.

If the internal appeal is denied, Wisconsin law allows you to request an external review by an independent review organization (IRO). The IRO's decision is binding on Security Health Plan. File the external review request within four months of the internal appeal denial.

For men whose total out-of-pocket cost for sildenafil remains prohibitive after exhausting insurance options, manufacturer patient assistance programs and telehealth platforms like HealthRX offer competitive pricing on generic ED medications, often at $2 to $4 per dose with a valid prescription.