Medicare Part D covers Eliquis, but your out-of-pocket cost depends on which plan you have and which pharmacy you use
Eliquis (apixaban) is a blood thinner prescribed to prevent blood clots and stroke. Most Medicare Part D plans cover it, though not all plans treat it the same way. Some plans place Eliquis on their formulary — the list of drugs they cover — while others may require you to try a different blood thinner first or pay more out of pocket. Your actual cost will depend on your specific plan, your pharmacy, and where you are in your coverage year.
Medicare Part B does not cover Eliquis because it is an oral medication you take at home, not an injection or infusion given in a medical setting. Part D is the prescription drug coverage that handles it. If you do not have Part D, you will pay the full retail price unless you have other coverage through a former employer or Medicaid.
Key Takeaways
- Most Medicare Part D plans cover Eliquis, but the amount you pay out of pocket varies by plan and pharmacy.
- Your Part D plan may require prior authorization, meaning your doctor must get approval before the pharmacy fills your prescription.
- You can compare Eliquis costs across different Part D plans and pharmacies using Medicare's online tool or by calling plans directly.
- If your plan's cost is too high, you can switch to a different Part D plan during the annual open enrollment period in the fall.
- Some manufacturers offer copay information programs that may lower your out-of-pocket cost even if your plan's copay is high.
How Part D coverage works for Eliquis
Part D plans are run by private insurance companies under contract with Medicare. Each plan decides which drugs to cover and at what cost. Eliquis is a brand-name drug, and many plans cover it, but some may list a generic or different blood thinner as their preferred option to keep costs down.
When a plan covers Eliquis, you typically pay a copay at the pharmacy — a fixed amount like $10, $35, or $50 per fill, depending on your plan. Some plans use coinsurance instead, meaning you pay a percentage of the drug's cost. Your copay or coinsurance applies toward your annual deductible and out-of-pocket maximum, both of which vary by plan.
Plans also use a tool called prior authorization to manage costs. This means your doctor must submit a request to the plan before the pharmacy can fill your Eliquis prescription. The plan reviews whether Eliquis is medically necessary for your condition. Most requests are approved, but the process can add a few days to getting your prescription filled.
What affects your out-of-pocket cost
Your actual cost for Eliquis depends on several factors. First is your plan choice — plans with lower monthly premiums often have higher copays for brand-name drugs, while plans with higher premiums may have lower copays. Second is your pharmacy. Prices can differ between chain pharmacies like CVS or Walgreens and independent pharmacies, and between mail order and in-person pickup.
Third is where you are in your coverage year. In the early months, you may still be paying toward your deductible. Once you meet your deductible, your copay kicks in. Later in the year, if your out-of-pocket spending reaches your plan's limit, Medicare covers the full cost. This limit varies by plan but is set by federal law each year.
Fourth is whether your plan requires you to try a different drug first. Some plans use a practice called step therapy, requiring you to try a generic blood thinner or a different brand-name drug before covering Eliquis. If that first drug does not work for you, your doctor can request an exception, and the plan usually approves it.
How to find out what your plan covers
The fastest way to learn your specific cost is to call your Part D plan directly. The phone number is on your insurance card. Tell them you take Eliquis and ask: What is my copay? Do I need prior authorization? Is there a deductible I have not met yet? They can answer all three in one call.
You can also use Medicare's Plan Finder tool at Medicare.gov. Enter your zip code, select your current plan, and search for Eliquis. The tool shows the copay amount and whether prior authorization is required. If you do not have a Part D plan yet or want to compare options, Plan Finder lets you see costs across all available plans in your area.
A third option is to call 1-800-MEDICARE and ask a representative to look up your coverage. They can also tell you if any plans in your area have lower copays for Eliquis than your current plan.
When to switch plans or ask for an exception
If your plan's copay for Eliquis is very high — say $50 or more per fill — you may save money by switching to a different Part D plan. You can make this change once a year during the annual open enrollment period, which runs from October 15 to December 7. Plans take effect January 1. If you are newly may be able to access for Medicare or had a major life change, you may be able to switch outside this window.
If your plan does not cover Eliquis at all or requires step therapy, your doctor can request a formulary exception. This is a formal request asking the plan to cover the drug even though it is not on their standard list. Plans must respond within 72 hours for urgent requests. Most exceptions are approved when a doctor explains that Eliquis is medically necessary.
If cost is the barrier, ask your doctor's office about the Eliquis copay information program run by the manufacturer, Bristol Myers Squibb. may be able to access patients may pay as little as $0 to $10 per month, regardless of their plan's copay. You must meet income limits, and the program does not work with certain plans like Medicaid or Veterans Affairs, but it is worth asking about.
What happens if you do not have Part D coverage
If you are on Original Medicare without Part D, you pay the full retail price for Eliquis at the pharmacy. This can be $300 to $400 per month depending on the pharmacy and dosage. You can enroll in Part D during the annual open enrollment period or if you have a may have access to life event like losing other drug coverage.
If you missed the enrollment important date and do not have a good reason, you may face a late enrollment penalty added to your Part D premium for as long as you have Medicare. The penalty is 1% of the national average Part D premium for each month you were without coverage. This is one reason to enroll as soon as you are may be able to access, even if you do not think you need it yet.
Questions to ask your doctor and pharmacist
Before your prescription is filled, ask your doctor: Does my plan require prior authorization for Eliquis, and can your office handle that? Is there a generic blood thinner that would work as well for my condition? If my plan does not cover Eliquis, will you request an exception?
At the pharmacy, ask: What is my copay today? Will this fill count toward my deductible or out-of-pocket maximum? Can you check if a different pharmacy has a lower price? Do you know about the manufacturer's copay information program?
Frequently Asked Questions
Does Medicare Part B ever cover Eliquis?
No. Part B covers medications given in a doctor's office or hospital, like injections or infusions. Eliquis is a pill you take at home, so Part D prescription drug coverage is what applies. If you do not have Part D, you pay out of pocket.
What if my plan says Eliquis is not covered?
Ask your doctor to request a formulary exception. Plans must review these requests within 72 hours for urgent cases. Most are approved when a doctor explains the medical reason. You can also switch to a different Part D plan during open enrollment if another plan in your area covers Eliquis with a lower copay.
Can I use a copay card if I have Medicare?
Copay information programs from the drug manufacturer may help, but they work differently than copay cards. You must meet income limits and cannot use them with Medicaid or VA coverage. Ask your doctor's office to check your may be able to access for the Bristol Myers Squibb information program.
What if I cannot afford my copay?
Talk to your doctor or pharmacist about the manufacturer's information program first. If you do not may have access to, ask about switching to a generic blood thinner your plan covers at a lower cost. Your doctor can also help you understand whether a different medication might work for your condition.
Do I need prior authorization every time I refill Eliquis?
Usually not. Prior authorization is typically required once when your prescription is first submitted. Refills usually go through without another authorization, unless your plan or dosage changes. If a refill is delayed, call your plan to ask why.