Medically reviewed by, Russell Braun RPH
You sit in the doctors office in disbelief. Your doctor just told you that he believes you have atrial fibrillation. In the back of your mind you remember friends and family members who have had this issue, knowing it is serious.
Will this result in a stroke?
All sorts of questions rush through your head and then your doctor says he would like to put you on a drug called Eliquis.
1. What is Eliquis?
Eliquis belongs to a newer class of drugs called Factor Xa (Ten a) inhibitors. The drug affects the ability of the blood to clot by interfering with one of the most important final steps in the clotting process.
The generic name is Apixaban, however at this time Eliquis is a brand only medication. You should take Eliquis twice a day. The drug is available in tablet form with two strengths 2.5mg and 5mg.
2. What does it treat?
Food and Drug Administration (FDA) approved used for Eliquis include:
- Reducing the risk of stroke and other blood clots in patients with nonvalvular atrial fibrillation.
- Prevention of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE)
- Treating an active DVT or PE that has already occurred in a patient.
Patients who have hip or knee replacements surgeries are at an increased risk of a blood clot. Eliquis prevents DVT and PE, due to this increased risk.
3. Alternative drugs
For many years warfarin (brand name Coumadin) was the only effective oral option for thinning the blood and preventing blood clots. Warfarin required close monitoring of patient with frequent blood tests. The International Normalized Ratio (INR) is the lab test used to monitor patients on warfarin. It is a measure of how long it takes the blood to clot. A variety of factors could affect the INR and the consequences are:
- INR too high risk of serious bleeding
- INR too low risk of blood clot
In 2010 a new oral anticoagulant was approved by the Food and Drug Administration. Since then, several oral anticoagulants have been approved and Eliquis is in that list. Others include:
- Pradaxa (Dabigatran)
- Xarelto (Rivaroxaban)
- Savaysa (Edoxaban)
If the Medicare plan you have doesn’t cover Eliquis one of these may be a covered alternative.
4. Is eliquis covered by Medicare?
There you sit staring back a the doctor after he revealed to your atrial fibrillation is a long term health issue. Many questions run through your head as you try to digest the diagnosis. The farthest thing from your mind is the cost of the drug you will need. Will Medicare cover it?
However, this question will quickly jump to the front of your mind when you get to the pharmacy!
According to the Eliquis website they claim that 94% of Medicare Advantage and Medicare Part D plans do cover Eliquis. This could change with time of course because plans can and do change their formularies frequently.
What is Medicare Advantage vs. original Medicare?
Medicare Advantage (MA) plans have come on strong in recent years. Advantage plans are sometimes referred to as Part C since Medicare is broken up into different parts. Basically advantage plans are just bundled services into one plan. They provide all of the components of Medicare in one plan, which includes prescription drug coverage.
MA plans include:
- Hospital insurance (Part A)
- Medical insurance (Part B)
- Prescription drug insurance (Part D)
Original Medicare requires that you pick each coverage component individually. Therefore, you would have a Prescription Drug Plan (PDP) separate from other coverage. Eliquis coverage would depend on the plan selected, tier of the drug and if the pharmacy is in network.
You can compare Medicare plans using the Medicare cost estimator tool for free.
5. What tier is Eliquis?
Each Medicare Prescription Drug Plan (PDP) has it’s own formulary. Eliquis is on most PDP formularies. However, the tier that Eliquis is in can vary from plan to plan.
What is a drug tier?
A tier is a grouping of drugs that work in the same way or are used to treat the same condition(s). The tier number given to each drug indicates how preferred it will be. The more preferred the less costly it is for the patient. Most Medicare plans have 5 tiers typically broken down this way.*
- Most preferred generic drugs
- Most preferred brand drugs
- Non preferred brand drugs
- Specialty drugs
* Not all Medicare tiers may be setup exactly the same way.
Eliquis is not available generically therefore, it would not be tier 1 or 2. Determining if it falls into tier 3 or 4 would be key to understand how much it will cost out of pocket. Tier 5 specialty drugs have the following characteristics:
- Very high cost
- Used to treat complex diseases
- Require special handling
- Frequently given in office or at a medical facility
Despite it’s high cost, Eliquis is not considered a specialty drug.
6. How much will my prescription cost with Medicare?
Great news! You determined the Medicare plan you have covers Eliquis. Now how can you figure out how much it will cost?
As noted earlier Eliquis is not available generically at this time. Therefore, it is pricey. According to GoodRx, a 30 day supply of Eliquis 5mg costs $448 if you are paying cash. That comes out to $5,376 per year if paying full cash price!
As noted above most Medicare drug plans will cover Eliquis to some extent. The actual cost will varying depending on a number of factors that could include:
- Drug tier
- Gap coverage
- Day supply, 30 versus 90 day mail order options
7. Cost estimator tools
Almost all insurance companies that administer Medicare health plans have cost estimator websites. If you want to see their offerings then the websites are fairly straightforward.
Taking one high cost drug like Eliquis can affect the plan you should choose. Gone are the days where you pick one plan from one insurer and stick with it for decades. Compare plans to see which provides the best coverage every year.
Instead of just looking at large insurer sites individually, comparing them against one another is a great idea. Q1Medicare.com is a website that allows you to easily compare different companies plans. Their Drug Coverage & Pricing Tool lets you enter your specific prescription drugs and see how much they will cost using that plan. It can be a very powerful way to save money on healthcare costs.
8. Look at the big picture
To protect your wallet taking all the components of Medicare benefits into account is very important. Don’t simply look at drug costs alone. Compare the components below side by side to ensure getting the best plan for you.
This is the monthly cost of having a prescription drug plan. Premiums are due every month without regard to any other healthcare usage. Monthly premiums range from low, medium or high. The higher the premium the lower the deductible will be.
Multiplying the monthly premium by twelve is an easy way to estimated plan costs.
A deductible is the amount of money the patient must pay before insurance kicks in to pay any portion. Standard Medicare plans have a $435 deductible per CMS guidelines. Deductibles can be lower than this amount and some plans may even have a $0 deductible. In those cases the trade off would be higher monthly premiums.
One month of Eliquis at $448 could cost you the entire annual deductible.
Copay / Coinsurance
Once the deductible is met, meaning you have paid the deductible amount out of your own pocket, the Initial Coverage Phase kicks in. All that means is that Medicare will start to pay for part of your prescriptions.
A copay is a flat amount you pay for drugs of a certain tier. Coinsurance is where you pay a percentage of the amount the drug costs.
- Copay = $25
- Coinsurance = 20% If Eliquis costs $448, coinsurance would be $448 x 20%= $89.60
Flat copays can be beneficial when expensive drugs like Eliquis are required and coinsurance costs run high.
Mail order simply means that the medication will be sent to you in the mail. This option is normally part of a Medicare benefit setup for maintenance medications. Maintenance refers to medications that are taken for long periods of time. They are filled for longer timeframes, typically 90 days, normally at a discount.
- Takes longer to get medication than picking up at a local pharmacy.
- The medication is delivered to your doorstep at lower cost and with less hassle.
9. How can I get help paying for eliquis?
Patient Assistance Programs are an underutilized resource for patients who take expensive medications. Patient Assistance Programs (PAP’s) are programs created by pharmacuetical manufacturers to help financially needy patients obtain necessary medications. For more information on these programs check out 11 Important Things to Know about Eliquis Patient Assistance and Alternatives.
The manufacturer of Eliquis offers the Bristol-Myers Squibb Patient Assistance Foundation to help patients offset drug costs. All patients enrolled in Medicare taking Eliquis should investigate this assistance offer. Needymeds.org is the easiest place to get information about the program. The form can be downloaded directly from their website.
The table below highlights key eligibility criteria that must be met in order to qualify for the assistance.
|Medicare patients eligibile?||Yes, if spend 3% or more of yearly household income on medications (not just Eliquis).|
|US Residency Required?||Must reside in US, Puerto Rico or US Virgin Islands.|
|Diagnosis||For outpatient use only.|
|Prescriber||Must be a licensed prescriber in the United states.|
|Income||300% of Federal Poverty Level (FPL). Patients should apply even if they are slightly above 300% as exceptions could be granted.|
|Decision notification||Patient and doctor notified in writing within one week.|
10. How much does Eliquis cost with regular insurance?
Commercial insurance will have varying levels of coverage for Eliquis similar to Medicare plans. However, patients not enrolled in Medicare have another option to help offset the costs of Eliquis. Bristol-Myers Squibb offers copay coupon cards.
These copay cards will pay for the patients portion of the deductible, copay or coinsurance they owe up to a certain limit. The Eliquis copay card currently offers:
- Pay as little as $10 per month
- Good for up to 24 months
- Annual maximum paid by the manufacturer is up to $3800.
11. How do I know if I qualify for copay support?
- Commerical insurance
- Insurance does not cover the full cost of Eliquis
- Medicare Part D
- Veterans Affairs (VA)
- Department of Defense (DOD)
- State health plans
Eliquis is an effective, yet very costly medication to treat and prevent blood clots. Weighing all the payment options via Medicare plans and patient assistance programs will provide the best outcome for you.
Click here to get Dr. Jason Reed’s exclusive list of medication questions you MUST ask your doctor, for FREE!
Have you tried Eliquis?
Please leave a comment and let everyone know if Eliquis worked for you. If you used any of these savings techniques please let me know what worked best.