CurrentHealth NetPolicy CP PCH.07

Sildenafil (Viagra) for ED

Policy governing medical necessity and coverage criteria for sildenafil (Viagra) for treatment of erectile dysfunction for Health Net/Centene-affiliated health plans (Commercial and HIM lines of business). Applies to providers submitting requests for sildenafil coverage.

Policy Summary

PayerHealth Net

PolicySildenafil (Viagra) for ED

Policy CodePolicy CP PCH.07

Change TypeAnnual review (clarifications)

Effective DateJun 1, 2018

Next Review Date

Key ActionSubmit prior authorization with documentation confirming ED diagnosis, age ≥18, use of generic sildenafil when brand requested unless contraindicated, and dose ≤100 mg/day.

SourceLink

POLICY UPDATE CHANGES

Added reference to generic sildenafil in the policy/criteria description to note that criteria apply to generic product as well.

Revised approval duration language for Commercial from 'length of benefit' to 'Benefit Renewal Date (quantity limits are plan specific)'.

Reference to generic sildenafil was added to indicate the criteria also apply to generic formulations.

References were reviewed and updated as part of the 2Q 2025 annual review.

25/50/100 mgAvailable tablet strengths

100 mg/dayMaximum allowed dose

Commercial, HIMLines of business covered

Nitrates/GC stim

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Coverage Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial Approval - ED diagnosis and age: Diagnosis of erectile dysfunction; member is >= 18 years of age

Generic-first requirement: If brand Viagra is requested, member must use generic sildenafil (25 mg, 50 mg, 100 mg) unless contraindicated or clinically significant adverse effects are experienced

Contraindicated co-medications: Sildenafil is not prescribed concurrently with nitrates or guanylate cyclase stimulators

See Appendix C for contraindications

Dose limits and plan quantity: Dose does not exceed 100 mg per day and complies with health plan approved quantity limits100 mg/day

Plan-specific quantity limits apply

Continuation Therapy

Covered for continuation when ANY of the following apply and ALL continuation conditions are met:

Continuation eligibility: Member is currently receiving medication via Centene benefit, or member previously met initial approval criteria, or member is in a state/product with continuity of care regulations

Refer to state-specific addendums for continuity rules

Response to therapy: Member is responding positively to therapy

Therapeutic failure alone does not justify continuation

Generic-first for brand requests: If brand Viagra is requested, member must use generic sildenafil (25 mg, 50 mg, 100 mg) unless contraindicated or clinically significant adverse effects are experienced

Dose increase limits: If request is for a dose increase, the new dose must not exceed 100 mg per day and must comply with health plan approved quantity limits

Non‑FDA approved indications that are not specifically addressed in this policy are not authorized unless the provider submits sufficient documentation of efficacy and safety consistent with the applicable off‑label use policies (see CP.CPA.09 for Commercial and HIM.PA.154 for Health Insurance Marketplace).

Coverage determinations under this policy are governed by the member’s plan documents and are subject to all terms, conditions, exclusions, and limitations of the member’s evidence of coverage, certificate of coverage, policy, or contract of insurance. This clinical policy is a guide to medical necessity and does not guarantee payment; applicable state and federal requirements and Health Plan administrative procedures also apply.

Uses that are non‑FDA approved and not listed in section III are not authorized unless the request meets the requirements of the applicable non‑formulary or off‑label policies. For drugs not on the formulary or PDL, follow the non‑formulary policy for the relevant line of business (CP.CPA.190 or HIM.PA.103). If the requested use (diagnosis, age, dosing) is not listed under exclusions and criterion above does not apply, consult the off‑label use policy (CP.CPA.09 for Commercial; HIM.PA.154 for Health Insurance Marketplace) and provide supporting evidence per those policies.

Coding

Covered codesmixed

N/A	No CPT/HCPCS/ICD codes listed in this policy text.

inv-07: Maximum daily dose — 100 mg/day

Maximum daily dose100 mg/day

Typical dosing regimen50 mg orally about 1 hour before sexual activity

Dose adjustment with ritonavirMax: 25 mg every 48 hours when co‑administered with ritonavir

Provider Actions & Requirements

Prior Authorization

Prior Authorization Guidance

Prior authorization required. This clinical policy provides guidance for medical necessity determinations and benefit administration for sildenafil (Viagra) for erectile dysfunction. Providers must submit a prior authorization request that documents the member meets the policy criteria (diagnosis of ED, member age ≥18, dose limits, contraindications such as concurrent nitrates or guanylate cyclase stimulators, etc.). Coverage decisions remain subject to the member's plan terms, exclusions, limitations, and applicable state/federal law.

Policy: CP PCH.07 — Effective 2018-06-01
Prior authorization must include documentation supporting all approval criteria

Documentation Required

Documentation Required — Denial Risk if Incomplete

Provider must submit supporting documentation (e.g., office chart notes, laboratory results, or other pertinent clinical information) with the PA request. Requests that lack required documentation or that request treatment for non‑FDA approved indications (without sufficient supporting evidence per off‑label use policies) may be denied.

Background

Sildenafil (Viagra) is a phosphodiesterase‑5 (PDE5) inhibitor indicated for the treatment of erectile dysfunction (ED). The typical dosing regimen for ED is 50 mg taken approximately 1 hour before sexual activity, with available tablet strengths of 25 mg, 50 mg, and 100 mg. The maximum recommended dose is 100 mg per day. Dose adjustments and cautions are necessary when sildenafil is co‑administered with interacting drugs.

Definitions

inv-17: ED — Erectile dysfunction; clinical indication for which sildenafil is FDA-approved.

Definition (ED)Erectile dysfunction; clinical indication for which sildenafil is FDA‑approved.

Typical indication descriptionTreatment of erectile dysfunction; sildenafil is a phosphodiesterase‑5 (PDE5) inhibitor.

Age requirementMember must be ≥ 18 years of age for coverage under initial approval criteria.

inv-18: Contraindicated co-medications — nitrates and guanylate cyclase stimulators (e.g., riociguat).

Contraindicated co‑medicationsOrganic nitrates/nitrites (nitric oxide donors) — use with sildenafil is contraindicated.

Guanylate cyclase stimulatorsCo‑administration with GC stimulators (e.g., riociguat/Adempas) is contraindicated.