Medicare covers Eliquis, but which part pays depends on how you get it

Eliquis (apixaban) is a blood thinner used to prevent blood clots and reduce stroke risk. Medicare does cover it, but whether your coverage applies and what you pay out of pocket depends on whether you fill the prescription at a pharmacy or receive it in a hospital or doctor's office.

If you take Eliquis by mouth at home — the most common way — Medicare Part D (prescription drug coverage) pays for it. If you receive it as an injection in a hospital or outpatient clinic, Medicare Part B covers it. The coverage rules, costs, and deductibles are different for each.

Your actual out-of-pocket cost also depends on which Medicare plan you have, whether you have reached your deductible, and whether your specific plan includes Eliquis on its formulary (the list of drugs it covers).

Key Takeaways

  • Eliquis taken at home is covered under Medicare Part D, and most Part D plans include it on their formulary.
  • Eliquis given in a hospital or doctor's office is covered under Medicare Part B, with different cost-sharing rules.
  • Your out-of-pocket cost depends on your specific plan, your deductible status, and whether you have reached the coverage gap.
  • You can check your plan's formulary online or call your plan's customer service to confirm Eliquis is covered before filling a prescription.
  • If your plan does not cover Eliquis or the cost is too high, you may be able to switch plans during the annual enrollment period or request a generic alternative.

How Medicare Part D covers Eliquis at the pharmacy

When you take Eliquis by mouth at home, Medicare Part D is the coverage that applies. Part D is optional prescription drug coverage you can add to Original Medicare, or it comes built into most Medicare Advantage plans.

Most Part D plans include Eliquis on their formulary. However, not all plans cover it the same way. Some plans may require you to try a different blood thinner first (called a prior authorization), or they may charge a higher copay for Eliquis than for a generic alternative. A few plans may not cover it at all, though this is uncommon.

Your out-of-pocket cost at the pharmacy depends on where you are in the Part D coverage cycle. Early in the year, you pay your plan's copay or coinsurance (usually $10 to $50 per month for a brand-name drug like Eliquis). Once you and your plan have spent a certain amount on drugs, you enter the coverage gap, where you pay a larger share of the cost. After you spend enough out of pocket, catastrophic coverage kicks in and your costs drop again.

How Medicare Part B covers Eliquis in a medical setting

Medicare Part B covers Eliquis if you receive it as an injection in a hospital outpatient department, an ambulatory surgery center, or a doctor's office. This is less common than taking it by mouth, but it happens in certain situations — for example, if you cannot swallow or need a dose before surgery.

Part B coverage works differently from Part D. You pay a 20% coinsurance after you meet your annual Part B deductible (which is $240 in 2024, but this amount changes yearly). The provider bills Medicare directly, and Medicare pays 80% of the approved amount. You are responsible for the remaining 20%.

If you have a Medigap or Medicare Advantage plan, your supplemental coverage may pay some or all of that 20% coinsurance, depending on your plan.

Checking whether your specific plan covers Eliquis

The only way to know for certain whether your plan covers Eliquis and what you will pay is to check your plan's formulary or call your plan directly. Do not assume coverage based on what worked for someone else — plans change their formularies every year, and each plan is different.

If you have Original Medicare with a Part D plan, log into your plan's website or call the customer service number on your insurance card. Ask whether Eliquis is on the formulary and what tier it is on (tier 1 drugs have the lowest copay, tier 4 or 5 have the highest). Ask whether prior authorization is required.

If you have a Medicare Advantage plan, the process is the same — check the plan's website or call the number on your card. Medicare Advantage plans include drug coverage, so you do not need a separate Part D plan.

If your doctor has already prescribed Eliquis, ask your doctor's office to check your coverage before you fill the prescription. Many offices have staff who can do this quickly and may be able to request a prior authorization if needed.

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

If your plan does not cover Eliquis or the copay is unaffordable, you have several options.

First, ask your doctor whether a generic blood thinner like apixaban (the generic version of Eliquis) is available and whether your plan covers it at a lower cost. Generic versions are chemically identical and work the same way, but they cost less. If your plan covers the generic but not the brand name, the generic is usually the better choice financially.

Second, check whether the manufacturer (Bristol Myers Squibb) offers a patient information program. Some drug makers provide discounts or free medication to people who meet income requirements. You can find this information on the drug's official website or by calling the manufacturer directly.

Third, if you are in the coverage gap (the period where you pay a larger share), remember that the gap closes automatically once you reach the out-of-pocket spending threshold. Ask your plan when you will reach catastrophic coverage so you know when your costs will drop.

Fourth, you can switch to a different Medicare plan during the annual enrollment period (October 15 to December 7 each year). If your current plan does not cover Eliquis well, you may find another plan that does and has a lower copay. You can compare plans on Medicare.gov.

Prior authorization and other coverage restrictions

Some Medicare plans require prior authorization before they will cover Eliquis. This means your doctor must submit a request to the plan explaining why Eliquis is medically necessary, and the plan must approve it before you fill the prescription.

Prior authorization usually takes a few business days. Your doctor's office typically handles the request, but you should follow up to make sure it was submitted and approved before you go to the pharmacy. If the plan denies the request, your doctor can appeal or request a different medication.

Some plans also use step therapy, which means you may have to try a cheaper blood thinner first. If that drug does not work or causes side effects, the plan will then cover Eliquis. This can delay treatment, so talk to your doctor about whether step therapy applies to your plan and what to do if the first drug does not work for you.

Frequently Asked Questions

Does Original Medicare cover Eliquis without a Part D plan?

No. Original Medicare (Parts A and B) does not cover prescription drugs taken at home. You must have a Part D plan to cover Eliquis at the pharmacy. If you do not have Part D, you can enroll during the annual enrollment period or within 63 days of losing other drug coverage to avoid a late enrollment penalty.

What is the difference between brand-name Eliquis and generic apixaban?

They are the same drug. Apixaban is the generic version, approved by the FDA and chemically identical to brand-name Eliquis. The main difference is cost — the generic is usually much cheaper. Both are covered by Medicare, but your plan may charge a lower copay for the generic.

Will my copay for Eliquis stay the same all year?

No. Your copay may increase once you enter the Part D coverage gap (usually after you and your plan have spent $5,030 on drugs in 2024, though this threshold changes yearly). Once you reach catastrophic coverage, your copay drops again. Check your plan's summary of benefits to see the copay amounts at each stage.

Can I get Eliquis covered if my doctor says it is medically necessary but my plan says no?

Yes, you can appeal. If your plan denies coverage or requires prior authorization that your doctor disagrees with, your doctor can file an appeal or request an exception. Medicare requires plans to have an appeals process, and your doctor can explain why Eliquis is the right choice for your condition.

What if I cannot afford the copay even with Medicare coverage?

Contact the drug manufacturer (Bristol Myers Squibb) to ask about patient information programs, which may reduce or waive your copay based on income. You can also ask your doctor's office about samples or discount programs. If cost remains a barrier, talk to your doctor about whether a different blood thinner covered at a lower cost might work for you.