Medicare covers Eliquis, but the amount you pay depends on which part of Medicare you have and which plan you chose

Eliquis (apixaban) is a blood thinner used to prevent blood clots and reduce stroke risk. Medicare Part D (prescription drug coverage) covers Eliquis at most plans, though you will pay a copay or coinsurance. Medicare Part B does not cover it — Part D does. The exact cost depends on your specific plan's formulary, which is the list of drugs it covers and at what price tier.

If you have Original Medicare plus a standalone Part D plan, your Part D plan decides whether Eliquis is covered and what you pay. If you have a Medicare Advantage plan (Part C), that plan includes drug coverage and makes its own coverage decisions. Neither type of plan is required to cover Eliquis, though most do because it is a commonly prescribed medication.

The cost you see at the pharmacy is not the same as what Medicare pays. Your out-of-pocket cost is determined by which tier Eliquis sits on in your plan — typically tier 2 or tier 3 — and whether you have met your deductible for the year.

Key Takeaways

  • Eliquis is covered by most Medicare Part D plans and most Medicare Advantage plans, but coverage is not automatic and varies by plan.
  • Your out-of-pocket cost depends on the tier your plan assigns to Eliquis and whether you have met your annual deductible.
  • You can check your specific plan's coverage by calling the plan directly, logging into your plan's website, or reviewing the formulary mailed to you each year.
  • If your plan does not cover Eliquis or the cost is too high, you can request a coverage exception or switch plans during the annual open enrollment period.
  • Generic versions of Eliquis are not yet available in the United States, so all prescriptions are for the brand-name drug.

How to learn about your specific plan covers Eliquis

The fastest way is to call your plan's customer service number, which is on your insurance card. Tell them you take Eliquis and ask what tier it is on and what your copay or coinsurance will be. They can answer in minutes. Have your prescription bottle handy so you can give them the exact dose (Eliquis comes in 2.5 mg and 5 mg tablets).

You can also check online. Log into your plan's website and search the formulary or drug list. Most plans let you search by drug name and see the tier, copay amount, and any restrictions. If you do not have online access, call and ask them to mail you a copy of the formulary or read it to you over the phone.

Your plan mails you an updated formulary every year, usually in the fall. If you have not received one recently, call and request it. The formulary shows which drugs are covered, which tier each one is on, and whether your doctor needs to get prior authorization before you can fill the prescription.

What the cost tiers mean and how they affect your Eliquis copay

Medicare Part D plans organize drugs into tiers, usually four or five levels. Tier 1 drugs (generic, lowest cost) have the lowest copay. Tier 2 and 3 drugs (brand-name and some generics) cost more. Tier 4 and 5 (specialty and high-cost drugs) have the highest copays. Eliquis is almost always on tier 2 or tier 3, which means your copay is typically $15 to $50 per month, though some plans charge coinsurance (a percentage of the drug's cost) instead of a flat copay.

Your copay also depends on which stage of the benefit year you are in. If you have not met your deductible yet, you may pay the full price until you do. Once you meet the deductible, you pay the copay. After you spend enough out of pocket to reach the coverage gap (also called the "donut hole"), your costs change again. After you exit the coverage gap, you pay a small copay for the rest of the year.

The exact dollar amounts change each year. For 2024, Part D deductibles range from $0 to $545 depending on your plan, and the coverage gap begins around $5,850 in total drug costs. Call your plan to find out where you stand in the benefit year right now.

Prior authorization and step therapy requirements

Some Medicare plans require prior authorization before they will cover Eliquis. This means your doctor has to contact the plan and get approval before you fill the prescription. It usually takes one to three business days. Your doctor's office handles this — you do not have to do it yourself, but you should ask your doctor to submit the request as soon as you get the prescription.

A few plans use step therapy, which means you have to try a different blood thinner first (usually warfarin or another cheaper option) and show that it did not work or caused side effects before the plan will cover Eliquis. If your plan has this requirement and your doctor believes Eliquis is the right choice for you, your doctor can request an exception. This takes longer — usually one to two weeks — so start the process early.

Call your plan and ask whether Eliquis requires prior authorization or step therapy. If it does, give your doctor the plan's phone number so they can submit the request directly.

What to do if your plan does not cover Eliquis or the copay is too high

If your plan does not cover Eliquis at all, or if the copay is unaffordable, you have three options: request a coverage exception, switch to a different plan, or look into patient information programs.

A coverage exception (also called a formulary exception) is a formal request to your plan asking them to cover a drug they normally do not, or to move it to a lower tier. Your doctor submits this request and explains why Eliquis is medically necessary for you. The plan has 72 hours to respond (or longer if your doctor says it is urgent). Many plans approve exceptions, especially if you have tried other blood thinners and they did not work.

If the exception is denied or you want a different plan, you can switch during the annual open enrollment period, which runs from October 15 to December 7 each year. You can also switch if you have a may have access to life event (like moving to a new state or losing other insurance). Use the Medicare Plan Finder tool on Medicare.gov to compare plans in your area and see which ones cover Eliquis at the lowest cost.

Bristol Myers Squibb, the manufacturer of Eliquis, offers a patient information program for people without insurance or with high out-of-pocket costs. You can learn about it by calling 1-855-354-7847 or visiting the Eliquis website. You must meet income requirements, and you cannot use it if you have Medicare, but some people use it as a bridge if they are waiting for coverage to begin.

How Eliquis costs compare across different Medicare plan types

Original Medicare plus a standalone Part D plan usually has lower monthly premiums but higher copays for brand-name drugs like Eliquis. You might pay $15 to $40 per month for Eliquis depending on the Part D plan you choose.

Medicare Advantage plans (Part C) bundle drug coverage into one plan and often have lower copays for brand-name drugs, sometimes $10 to $25 per month for Eliquis. However, Advantage plans have network restrictions — you have to use doctors and pharmacies in the plan's network, or pay more. Some Advantage plans also require prior authorization for Eliquis.

The best choice depends on your doctors, your pharmacy, and your other medications. Use the Medicare Plan Finder to compare the total annual cost of your medications across different plans in your area. Enter all your drugs, your pharmacy, and your doctors' names, and the tool will show you the estimated out-of-pocket cost for each plan.

Frequently Asked Questions

Will Medicare cover Eliquis if I take it for atrial fibrillation?

Yes. Medicare Part D covers Eliquis for atrial fibrillation (to reduce stroke risk), for deep vein thrombosis (DVT), and for pulmonary embolism (PE). The indication does not change whether it is covered — your plan's formulary determines coverage, not the reason your doctor prescribed it.

What if I cannot afford the copay even after a coverage exception?

Ask your doctor about patient information programs run by the drug manufacturer, or contact your local Area Agency on Aging to ask about pharmaceutical information programs in your state. Some nonprofits also help seniors pay for medications. Your pharmacist can sometimes suggest lower-cost alternatives or ways to reduce the copay.

Can I use a GoodRx coupon or discount card with Medicare?

No. If you have Medicare Part D, you cannot use GoodRx or other discount cards — your Part D coverage takes priority. Using a discount card instead of your insurance can actually hurt you because the discount does not count toward your deductible or out-of-pocket maximum. Always use your Medicare card at the pharmacy.

Does Medicare cover Eliquis if I am in the coverage gap?

Yes, but you pay more. In the coverage gap, you pay 25% of the drug's cost (as of 2024). Once you exit the gap and reach catastrophic coverage, you pay a small copay again. Call your plan to find out how much you have spent so far this year and when you will exit the gap.

What happens to my Eliquis coverage if I move to a different state?

Your current plan may not be available in your new state. You can keep your current plan if it is available there, or you must switch to a plan offered in your new state. You have 60 days after you move to make changes without waiting for open enrollment. Contact Medicare at 1-800-MEDICARE or log into Medicare.gov to update your address and see which plans are available where you are moving.