Vaginal Estrogen and Sildenafil Prescription Medicare Coverage: A Cross-Sectional Study

INTRODUCTION: Vaginal estrogen is an essential medication for many postmenopausal women. However, cost can be a prohibitive factor for many patients, and insurance coverage can be difficult to predict. In a landscape where disparities in medical coverage between men and women are more frequently described, this study sought to compare coverage between vaginal estrogen and sildenafil, medications with substantial impact on the sexual function of aging communities. OBJECTIVE: The objective of this study was to describe the insurance coverage of generic vaginal estrogen cream, branded-generic Yuvafem suppositories, and sildenafil in terms of median out-of-pocket cost and insurance coverage scores. METHODS: This is a cross-sectional study examining out-of-pocket cost and insurance coverage scores of generic vaginal estrogen cream, branded-generic Yuvafem, and sildenafil in the United States for Medicare insurance plans in 2024. Census data was used to identify the most populous three districts in each state. All insurance plans for the top ten Medicare insurers in each district were then reviewed for the median cost and tier of the three medications. A proprietary weighted coverage score ranging from 0.2 to 1.0 was then adopted based on the proportion of tier coverage for each formulation where a higher coverage score indicated better coverage. Analyses were performed using STATA. RESULTS: One thousand nine hundred and forty-two insurance plans were ultimately included in the analysis. The median cost of estradiol cream was $20.5 (IQR $16.5 to $42.5), while Yuvafem had a median cost of $39 (IQR $33 to $43). Sildenafil had the lowest median cost of $16 (IQR $16 to $319). Estradiol cream had the highest coverage score (0.67) compared to Yuvafem or sildenafil, with coverage scores of 0.55 and 0.4, respectively. Kaiser had the highest coverage scores for both vaginal estrogens, with an average coverage score of 0.80, whereas Anthem had the lowest coverage scores for estradiol cream (0.58) and Yuvafem (0.40). Alaska had the lowest coverage scores for both estradiol cream (0.53) and Yuvafem (0.37), while Mississippi had the highest for both formulations (0.77 and 0.66, respectively). South Dakota had the lowest coverage score for sildenafil (0.33), while Florida had the highest (0.58) (Figure 1). CONCLUSIONS: Despite a lower coverage score than either the estrogen cream or Yuvafem, sildenafil may be more affordable for men than vaginal estrogen is for women. Living in Alaska or having Anthem insurance may result in worse coverage of vaginal estrogen (Table 1).