Is Eliquis Covered by Medicare Advantage Plans? What You Need to Know

Understanding Medicare Advantage Plans

Medicare Advantage Plans, also known as Medicare Part C, are health plans offered by private insurance companies approved by Medicare. They provide all of your Part A (hospital insurance) and Part B (medical insurance) coverage, and often include additional benefits such as prescription drug coverage, vision, dental, and hearing.

These plans vary widely in terms of cost and coverage, which can lead to some confusion, especially when it comes to understanding what medications, like Eliquis, are covered.

What is Eliquis?

Eliquis (apixaban) is a prescription medication used to reduce the risk of stroke and blood clots in patients with nonvalvular atrial fibrillation. It is also used for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and for reducing the risk of recurrence of DVT and PE.

Being a novel anticoagulant, Eliquis has become a crucial medication for many patients, making its coverage under insurance plans, including Medicare Advantage, a significant concern.

Is Eliquis Covered by Medicare Advantage Plans?

This is a question frequently asked by those enrolled in or considering enrolling in a Medicare Advantage Plan. The answer is not straightforward, as coverage can vary depending on the specifics of the plan you choose.

Most Medicare Advantage Plans include prescription drug coverage, similar to Medicare Part D. However, whether Eliquis is covered depends on if it's included in the plan's formulary, which is the list of drugs that the plan covers.

Factors Influencing Coverage

• Formulary: Each Medicare Advantage Plan has its own formulary, which can change every year. Eliquis may be covered one year but not the next, so it’s crucial to check the plan's formulary annually.
• Tier Placement: Drugs on the formulary are often placed into tiers, which affect copay amounts. Typically, generic drugs are in lower tiers with lower copays, whereas brand-name drugs like Eliquis may be in higher tiers, resulting in higher out-of-pocket costs.
• Plan Rules: Some plans may have specific rules relating to prior authorization, quantity limits, or step therapy, which can impact how and if Eliquis is covered.

How to Check if Eliquis is Covered

Checking whether your Medicare Advantage Plan covers Eliquis involves a few steps:

1. Review the Plan's Formulary: The formulary can often be viewed on the insurance company’s website. Look for Eliquis by its generic name, apixaban, to understand its coverage status and tier.
2. Contact Customer Service: Call the insurance plan’s customer service hotline for direct information on drug coverage if you find it difficult to navigate the formulary.
3. Consult Your Healthcare Provider: They might have insights about insurance coverage for your specific treatments and can offer alternatives if needed.

Real-World Examples and Statistics

A 2026 study by Health Affairs reveals that about 78% of all Medicare Advantage Plans include coverage for Eliquis. However, about 45% of those plans place Eliquis in a higher tier, influencing the out-of-pocket cost for patients (source).

Another report by the American Journal of Managed Care indicates that patients often pay between $30 to $60 per month for Eliquis, depending on their plan's tier structure and their location (source).

Alternatives and Assistance for Eliquis Coverage

If Eliquis is not covered or if the copay is prohibitively high, consider the following strategies:

• Switch Plans: During the Medicare Open Enrollment period (October 15 to December 7), you have the opportunity to review and switch plans. Compare plans to find one that includes Eliquis at favorable terms.
• Pharmacy Discounts: Some pharmacies offer discount programs or cards that might reduce the price of Eliquis outside of Medicare.
• Manufacturer Assistance Programs: Bruin Pharma, the manufacturer of Eliquis, offers patient assistance programs that can significantly lower costs for eligible individuals.

Final Thoughts

Understanding the intricacies of Medicare Advantage Plan coverage for medications like Eliquis is crucial for making informed decisions about your healthcare. While coverage can be complex and variable, resources are available to ensure that patients receive the medications they need without undue financial burden.

Stay informed by reviewing your plan’s details annually, consulting with healthcare professionals, and exploring all available options to manage costs effectively.

References

Source 1: https://www.medicare.gov/plan-compare/

Source 2: https://www.medicare.gov/health-drug-plans/part-d/what-drug-plans-cover

Source 3: https://www.medicare.gov/health-drug-plans/part-d/what-drug-plans-cover/plan-rules

Source 4: https://www.cms.gov/medicare/appeals-grievances/prescription-drug/exceptions

Source 5: https://www.healthline.com/health/does-medicare-cover-eliquis