OBJECTIVES: Oral pharmacotherapy is considered a first-line management option for erectile dysfunction (ED), yet many men discontinue the therapy, thereby requiring further intervention. Given US healthcare spending concerns, this cost analysis estimated the Medicare patient costs of guideline-recommended non-oral therapies for ED.

METHODS: A cost analysis was developed using men with moderate-to-severe ED covered by Fee-for-Service Medicare as index patients. The 2018 American Urological Association (AUA) guidelines for ED were used to identify available non-oral therapies and the Medicare Coverage Database was used to retrieve coverage policies for each treatment. For treatments with positive Medicare coverage decisions, 2023 patient out-of-pocket costs were retrieved from the 2023 Centers for Medicare & Medicaid Services Final Rule. Annual cash prices for treatment options without positive Medicare coverage were extracted from published literature and inflated to 2022 dollars or obtained from the GoodRx platform.

RESULTS: The AUA guidelines recommend four non-oral treatments for men with ED: 1. vacuum erection device (VED; moderate recommendation), 2. intraurethral alprostadil (IA; conditional recommendation), 3. intracavernosal injections (ICI; moderate recommendation), and 4. inflatable penile prosthesis (IPP; strong recommendation), while low-intensity extracorporeal shock wave therapy (ESWT) is considered investigational (conditional recommendation). Medicare has established national coverage for IPP, non-coverage for VED, and no published coverage policies for ICI, IA, or ESWT. In this analysis, an annual IA prescription was associated with the highest patient costs ($4,022), followed by an annual ICI prescription ($3,947), one ESWT treatment course ($3,445), IPP as an outpatient procedure ($1,600), and one VED unit ($213).

CONCLUSIONS: IA is conditionally recommended by the AUA and associated with the highest patient out-of-pocket cost. IPP has a strong guideline recommendation and is associated with lower costs than IA. IPP should be considered a cost-competitive and effective option for men with ED who fail oral pharmacological management.