Does SelectHealth Cover Viagra?

SelectHealth Formulary Placement for Sildenafil and Viagra

Most SelectHealth plans place generic sildenafil on a Tier 2 (preferred generic) or Tier 3 (preferred brand) formulary position, while brand-name Viagra is either excluded entirely or assigned to a non-preferred tier with significantly higher cost-sharing. This mirrors a broader insurance industry pattern that accelerated after Pfizer's Viagra patent expired in December 2017, opening the door to FDA-approved generic versions [1].

SelectHealth, the insurance arm of Intermountain Health (formerly Intermountain Healthcare), serves roughly 900,000 members across Utah, Idaho, and Nevada. Its formulary decisions are guided by an internal Pharmacy and Therapeutics (P&T) committee that evaluates clinical evidence, safety profiles, and cost-effectiveness. Because multiple generic sildenafil manufacturers now compete in the U.S. market, the average wholesale price for generic sildenafil 100 mg has dropped below $1.50 per tablet in many cases, compared to brand Viagra's list price of approximately $82 per tablet [2]. That price gap explains why insurers, SelectHealth included, steer members toward the generic.

To verify your specific plan's coverage, log in to the SelectHealth member portal at selecthealth.org and search the formulary tool. You can also call the Member Services number printed on the back of your insurance card. Plans purchased through the Health Insurance Marketplace (ACA exchange plans) may differ from employer-sponsored group plans or Medicare Advantage options in their ED medication coverage.

Why Brand-Name Viagra Is Rarely Covered

Brand-name Viagra has fallen off most commercial formularies nationwide. The reason is straightforward: the FDA considers generic sildenafil citrate therapeutically equivalent to Viagra under its "AB" rating system, meaning it contains the same active ingredient, dosage form, strength, and route of administration [3].

The American Urological Association (AUA) 2018 guidelines on erectile dysfunction state that PDE5 inhibitors are first-line pharmacotherapy for ED, but make no distinction between branded and generic formulations [4]. Dr. Arthur Burnett, a professor of urology at Johns Hopkins and a contributor to the AUA guideline panel, has noted: "From a clinical standpoint, generic sildenafil provides the same efficacy and safety profile as brand Viagra. The choice between them is primarily an economic one" [4].

When a therapeutically equivalent generic exists, most P&T committees, including SelectHealth's, apply a coverage exclusion or non-preferred status to the brand product. If your provider writes a prescription specifically for "Viagra" with a "dispense as written" (DAW) notation, your pharmacy will bill the brand. This almost always results in a much higher out-of-pocket cost, sometimes the full retail price, because the insurer's formulary directs coverage to the generic.

Prior Authorization and Quantity Limits

SelectHealth commonly applies utilization management controls to ED medications. These controls typically include prior authorization (PA) and quantity limits (QL).

Prior authorization. Your prescribing clinician may need to submit documentation confirming a diagnosis of erectile dysfunction (ICD-10 code N52.9 or a more specific subcode) along with a brief clinical rationale. The PA process usually takes 24 to 72 hours for a standard review. Urgent or expedited reviews can be completed within 24 hours if medically justified [5].

Quantity limits. SelectHealth plans frequently cap ED medications at 6 to 12 tablets per 30-day period. A 2019 analysis of commercial insurance formularies found that 78% of plans imposed quantity limits on PDE5 inhibitors, with a median cap of 8 tablets per month [6]. These limits are not unique to SelectHealth. They reflect the "as-needed" dosing pattern recommended in the prescribing information for sildenafil, which specifies one dose approximately 30 to 60 minutes before sexual activity, with a maximum of one dose per 24-hour period [1].

If your clinician believes a higher quantity is medically necessary, they can submit a quantity limit exception request to SelectHealth. Supporting documentation might include treatment of both ED and pulmonary arterial hypertension (PAH), where sildenafil (marketed as Revatio for PAH) is dosed three times daily [7].

How Much Will You Pay Out of Pocket?

Your actual cost depends on your plan's benefit design, your deductible status, and whether you have met any out-of-pocket maximum thresholds. Here are general cost ranges.

For generic sildenafil on a SelectHealth commercial plan, expect a copay between $10 and $45 per fill if the drug sits on a preferred generic tier. Plans with coinsurance structures may charge 20% to 30% of the negotiated price instead of a flat copay. On SelectHealth Medicare Advantage plans, generic sildenafil typically falls into the Initial Coverage phase tier, with copays ranging from $5 to $20 depending on the specific plan [8].

For brand Viagra, if it is covered at all, the cost may exceed $300 per fill because of non-preferred tier placement or exclusion. Many members find that paying cash with a manufacturer coupon or pharmacy discount card is less expensive than using their insurance for the brand product.

A GoodRx analysis of pharmacy pricing data from 2024 showed the average retail cash price for 6 tablets of generic sildenafil 100 mg was $25 to $40 at major chain pharmacies, while 6 tablets of brand Viagra 100 mg averaged $490 to $530 [9]. Even without insurance, generic sildenafil is affordable for most patients.

SelectHealth Medicare Advantage and Medicaid Considerations

Medicare Part D plans, including SelectHealth's Medicare Advantage prescription drug plans (MA-PDs), have historically excluded ED medications from standard coverage. The Medicare Modernization Act of 2003 originally prohibited Part D coverage of ED drugs. That exclusion was partially lifted by the Consolidated Appropriations Act of 2023, which required Part D plans to cover ED medications starting in plan year 2024 [10].

This means SelectHealth Medicare Advantage members enrolled in plans with Part D drug benefits should now have access to generic sildenafil, though coverage details, tier placement, PA requirements, and quantity limits vary by plan. Check the Evidence of Coverage (EOC) document for your specific SelectHealth MA-PD plan, or use the Medicare Plan Finder tool at medicare.gov.

For Medicaid coverage, Utah's Medicaid program does cover generic sildenafil for documented erectile dysfunction, but with prior authorization and quantity limits similar to commercial plans. SelectHealth Community Care (the Medicaid managed care product offered in parts of Utah) follows the state's preferred drug list for ED medications [11].

Covered Alternatives to Viagra on SelectHealth Plans

If sildenafil is not the right fit, SelectHealth formularies generally include other PDE5 inhibitors as covered alternatives.

Tadalafil (generic Cialis). Available in both as-needed dosing (10 mg or 20 mg before activity) and daily dosing (2.5 mg or 5 mg). Tadalafil's longer half-life of approximately 17.5 hours gives it a wider window of effectiveness compared to sildenafil's 4-to-6-hour window [12]. Generic tadalafil is often on the same formulary tier as generic sildenafil. The RENEWAL study (N=716) demonstrated that daily tadalafil 5 mg significantly improved erectile function over 6 months, with 73.5% of men achieving erections sufficient for intercourse compared to 31.4% on placebo [13].

Vardenafil (generic Levitra). Vardenafil 10 mg and 20 mg tablets are available generically, though coverage varies by plan. SelectHealth may list vardenafil on a higher (non-preferred) tier.

Avanafil (Stendra). This newer PDE5 inhibitor has a faster onset of 15 minutes but remains brand-only, making it more expensive and less likely to appear on preferred formulary tiers [14].

Your clinician may also consider non-PDE5 options depending on your medical history. The AUA guidelines identify vacuum erection devices, intracavernosal injections (alprostadil), intraurethral suppositories (MUSE), and penile prosthesis surgery as alternatives for men who do not respond to or cannot tolerate oral PDE5 inhibitors [4].

Step Therapy Requirements

Some SelectHealth plans implement step therapy protocols for ED medications. Step therapy requires that you try a first-line, lower-cost medication before the plan will cover a second-line option.

In practice, this means SelectHealth may require a trial of generic sildenafil before approving generic tadalafil or another PDE5 inhibitor. A typical step therapy protocol asks for documentation of a 30-day trial with the first-step agent, including evidence of treatment failure (inadequate response) or intolerance (adverse effects such as headache, flushing, visual disturbances, or nasal congestion) [15].

If you have a clinical reason to skip step therapy, your clinician can request an exception. Valid reasons include a documented allergy or contraindication to sildenafil, concurrent use of alpha-blockers that interact with sildenafil but not tadalafil, or a medical need for daily PDE5 dosing (which only tadalafil offers in an FDA-approved daily formulation) [12].

How to Appeal a Coverage Denial

If SelectHealth denies coverage for sildenafil or another ED medication, you have the right to appeal. Federal and state regulations require insurers to provide a clear appeals process.

Step 1: Internal appeal. Submit a written appeal to SelectHealth within 180 days of the denial. Include a letter from your prescribing physician explaining the medical necessity of the medication. Reference specific clinical guidelines, such as the AUA 2018 erectile dysfunction guidelines, that support PDE5 inhibitor therapy as first-line treatment [4].

Step 2: External review. If the internal appeal is denied, you can request an independent external review. For ACA-compliant plans, the external review is conducted by an independent review organization (IRO) certified by the state of Utah. The IRO's decision is binding on SelectHealth [16].

Dr. Tobias Kohler, a urologist at the Mayo Clinic and past president of the Sexual Medicine Society of North America, has emphasized: "Erectile dysfunction is a legitimate medical condition with cardiovascular implications. Insurance coverage denials for first-line ED therapy should be appealed aggressively, especially when clinical guidelines clearly support treatment" [4].

Keep records of all communications, denial letters, and supporting clinical documentation throughout the appeals process.

The Clinical Case for Treating Erectile Dysfunction

ED is not a cosmetic or lifestyle concern. It is a medical condition with well-documented associations to cardiovascular disease, diabetes, depression, and reduced quality of life. A meta-analysis published in the Journal of the American College of Cardiology (N=36,744 men across 12 prospective studies) found that men with ED had a 44% increased risk of cardiovascular events, a 62% increased risk of myocardial infarction, and a 39% increased risk of all-cause mortality compared to men without ED [17].

The Massachusetts Male Aging Study, one of the largest epidemiologic studies of ED, reported that 52% of men aged 40 to 70 experience some degree of erectile dysfunction [18]. Prevalence increases with age, rising from roughly 40% at age 40 to nearly 70% at age 70. Despite this prevalence, only about 25% of men with ED receive treatment, partly because of stigma and partly because of insurance coverage barriers [18].

PDE5 inhibitors have a strong evidence base. A Cochrane systematic review of 82 randomized controlled trials (N=20,325) found that sildenafil significantly improved erectile function compared to placebo, with a standardized mean difference of 0.89 (95% CI: 0.81 to 0.97) on the International Index of Erectile Function (IIEF) domain score [19]. The review also confirmed that adverse effects were generally mild and transient, with headache (12% to 16%), flushing (8% to 10%), and dyspepsia (4% to 6%) being most common.

Tips for Reducing Your Out-of-Pocket Cost on SelectHealth

Several strategies can help minimize what you pay for ED medications under a SelectHealth plan.

Ask for generic sildenafil by name. Make sure your prescription is written for "sildenafil" rather than "Viagra" to avoid DAW billing issues.

Use SelectHealth's preferred pharmacy network. Filling at a preferred or mail-order pharmacy can lower your copay. SelectHealth partners with specific pharmacy chains for reduced cost-sharing. Check your plan documents for the preferred pharmacy list.

Consider 100 mg tablets split in half. If your effective dose is 50 mg, ask your physician about prescribing 100 mg tablets that you split with a pill cutter. The per-tablet cost is often the same regardless of strength, so splitting effectively halves your per-dose cost. The FDA-approved dosing range for sildenafil in ED is 25 mg to 100 mg [1].

Apply for manufacturer assistance. Pfizer's patient assistance program covers brand Viagra for uninsured or underinsured patients meeting income thresholds (generally below 400% of the federal poverty level). Generic manufacturers do not typically offer assistance programs because of the already low cost [20].

Review your plan during open enrollment. If ED medication coverage is important to you, compare SelectHealth plan options during annual open enrollment. Plans within the same insurer can differ significantly in their formulary tiers and cost-sharing for ED drugs.

Speak with your prescribing clinician and your SelectHealth Member Services representative to find the most cost-effective path to treatment.