What Insurance Covers Eliquis: A Comprehensive Guide

Most prescription drug insurance plans, including private health insurance, Medicare (Part D and Medicare Advantage), and government-sponsored programs like Medicaid, generally cover Eliquis (apixaban). However, the extent of coverage, including copays, coinsurance, and any prior authorization requirements, will depend on the specifics of your individual plan. Let’s unpack this further.

Understanding Insurance Coverage for Eliquis

Navigating the world of prescription drug coverage can feel like deciphering ancient hieroglyphics. But understanding the basics of how your insurance handles Eliquis, a crucial anticoagulant medication, can save you time, money, and a whole lot of frustration.

Private Health Insurance and Eliquis

If you receive your health insurance through your employer or purchase it privately, your coverage for Eliquis will be dictated by your plan’s formulary and specific rules.

• Formulary Tiers: Most private plans use a tiered formulary, which categorizes medications based on cost. Eliquis, being a brand-name drug, is typically placed on a higher tier, resulting in a higher copay compared to generic medications.
• Prior Authorization: Many plans require prior authorization before covering Eliquis. This means your doctor needs to submit documentation to your insurance company justifying the medical necessity of the medication. They’ll need to demonstrate why Eliquis is the most appropriate treatment option for your specific condition.
• Step Therapy: Some plans employ step therapy, requiring you to try a less expensive anticoagulant (like warfarin) before they’ll cover Eliquis. This approach is aimed at cost-containment.
• Coverage Limitations: Your plan might have quantity limits on how much Eliquis you can receive per month.

Medicare and Eliquis: Part D and Medicare Advantage

Medicare offers prescription drug coverage through Part D plans and Medicare Advantage (Part C) plans, which often include prescription drug benefits.

• Medicare Part D: Stand-alone Medicare Part D plans have their own formularies and cost-sharing structures. Similar to private insurance, Eliquis will likely be on a higher tier, resulting in a higher copay. Medicare Part D also has coverage stages (deductible, initial coverage, coverage gap/”donut hole”, and catastrophic coverage), and your cost for Eliquis will vary depending on which stage you’re in.
• Medicare Advantage (Part C): These plans are offered by private insurance companies and contract with Medicare. They also have their own formularies and cost-sharing arrangements. The coverage rules for Eliquis are very similar to standalone Medicare Part D plans.
• Low-Income Subsidy (LIS): Medicare offers a Low-Income Subsidy (LIS), also known as Extra Help, to individuals with limited income and resources. LIS can significantly reduce your out-of-pocket costs for Eliquis.

Medicaid Coverage for Eliquis

Medicaid, a joint federal and state program, provides healthcare coverage to low-income individuals and families. Medicaid coverage for Eliquis varies by state.

• State-Specific Formularies: Each state has its own Medicaid formulary. Eliquis is generally covered, but some states may require prior authorization or have other restrictions.
• Low Copays: Generally, Medicaid beneficiaries have very low copays for prescription drugs, including Eliquis.
• Dual Eligibility: Individuals who are eligible for both Medicare and Medicaid (often referred to as “dual eligibles”) typically receive their prescription drug coverage through Medicare Part D.

Patient Assistance Programs and Savings Cards

Even with insurance, the cost of Eliquis can be a burden. Fortunately, there are resources available to help.

• Bristol Myers Squibb and Pfizer Patient Assistance Program: The manufacturers of Eliquis offer a Patient Assistance Program (PAP) for eligible individuals who meet certain income and insurance requirements. This program can provide Eliquis at little to no cost.
• Eliquis Savings Card: The manufacturers also offer a savings card that can reduce your copay if you have commercial insurance. However, it is often not valid if you are enrolled in a government-funded program like Medicare or Medicaid.
• Non-Profit Organizations: Several non-profit organizations offer financial assistance for prescription drugs. These organizations often have specific eligibility criteria and application processes.

Frequently Asked Questions (FAQs) About Eliquis Insurance Coverage

Here are some common questions about Eliquis coverage, answered for your convenience.

1. Will my insurance automatically cover Eliquis?

No, coverage is not automatic. Most insurance plans require you to fill your prescription and pay your copay or coinsurance. Additionally, many plans require prior authorization before they will cover Eliquis.

2. What is prior authorization, and how do I get it for Eliquis?

Prior authorization is a requirement from your insurance company that your doctor needs to obtain approval before they will cover Eliquis. Your doctor will need to submit documentation demonstrating the medical necessity of the medication. Contact your insurance company or your doctor’s office for specific instructions on the prior authorization process.

3. My insurance denied my Eliquis claim. What should I do?

First, understand the reason for the denial. Review the explanation of benefits (EOB) you received from your insurance company. You can then file an appeal, providing any additional information that supports the medical necessity of Eliquis. Your doctor can also assist with the appeal process.

4. Does Medicare Part D cover Eliquis?

Yes, Medicare Part D plans generally cover Eliquis. However, the specific cost-sharing (copay or coinsurance) will depend on the plan’s formulary and your current coverage stage.

5. What is the “donut hole” in Medicare Part D, and how does it affect my Eliquis costs?

The “donut hole,” or coverage gap, is a stage in Medicare Part D where you pay a higher percentage of your prescription drug costs. While this gap is gradually closing, it can still impact your out-of-pocket expenses for Eliquis.

6. Can I use a manufacturer’s savings card if I have Medicare Part D?

Generally, no. Savings cards offered by manufacturers are usually not valid for individuals enrolled in government-funded programs like Medicare or Medicaid. Check the specific terms and conditions of the savings card for details.

7. Does Medicaid cover Eliquis?

Yes, Medicaid generally covers Eliquis, but coverage varies by state. Some states may require prior authorization or have other restrictions.

8. What is the Bristol Myers Squibb and Pfizer Patient Assistance Program (PAP)?

The Bristol Myers Squibb and Pfizer PAP provides Eliquis at little to no cost to eligible individuals who meet certain income and insurance requirements. Check their website for eligibility criteria and application details.

9. Are there generic alternatives to Eliquis?

Currently, there is no generic version of Eliquis (apixaban) available in the United States.

10. How can I find out which tier Eliquis is on in my insurance formulary?

Contact your insurance company directly or visit their website. Most insurance companies have online formularies that you can search to determine the tier placement of specific medications.

11. What if my insurance requires me to try warfarin before Eliquis (step therapy)?

If your insurance requires step therapy, discuss this with your doctor. If warfarin is not appropriate for your condition, your doctor can submit documentation to your insurance company explaining why Eliquis is medically necessary.

12. How often does my prior authorization for Eliquis need to be renewed?

The frequency of prior authorization renewal varies by insurance plan. Some plans require renewal every year, while others may require it more frequently. Check with your insurance company for specific details.

By understanding your insurance coverage and exploring available resources, you can navigate the financial aspects of taking Eliquis with greater confidence. Remember to communicate openly with your doctor and insurance provider to ensure you receive the medication you need at the most affordable price possible.