The Truth: Most Medicare Plans Do Cover Eliquis
The query “Why does Medicare not pay for Eliquis?” stems from a widespread misunderstanding of how Medicare covers prescription drugs. While Original Medicare (Parts A and B) doesn't cover most outpatient prescriptions, Eliquis (apixaban) is covered by the vast majority of Medicare Part D and Medicare Advantage (Part C) plans that include prescription drug benefits.
Original Medicare primarily covers drugs administered in a hospital or clinic, not those you take at home. To have Eliquis covered for at-home use, you need separate prescription drug coverage.
The Role of Medicare Part D and Medicare Advantage
Medicare Part D (Prescription Drug Plans)
Medicare Part D plans, offered by private insurers, are the primary way Original Medicare beneficiaries get coverage for retail prescriptions. Most Part D plans include Eliquis on their list of covered drugs, known as a formulary. Drugs on a formulary are grouped into tiers, which determine your cost-sharing. As a brand-name drug without a generic on the market, Eliquis is typically placed on a higher, more expensive tier, such as Tier 3.
Medicare Advantage (Part C) Plans
Medicare Advantage plans combine Part A and Part B coverage and often include prescription drug coverage. If your Advantage plan includes drug benefits, Eliquis is likely covered, but costs will vary based on the plan's specific terms, including its formulary and cost-sharing structure.
Factors Influencing Your Eliquis Costs on Medicare
Your out-of-pocket costs for Eliquis depend on several factors:
- Formulary Tier: Higher tiers mean higher copayments or coinsurance.
- Annual Deductible: You typically pay the full cost until you meet your plan's annual deductible. The maximum Part D deductible in 2025 is $590.
- Coverage Stages: Your costs change as you move through the different phases of Part D coverage: deductible, initial coverage, the coverage gap (donut hole), and catastrophic coverage.
- Utilization Management: Some plans require prior authorization (pre-approval from the plan) or step therapy (trying a cheaper drug first).
Comparison of Eliquis Coverage Scenarios
| Feature | Original Medicare (Part A & B Only) | Medicare Part D Plan | Medicare Advantage (Part C) with Drug Coverage |
|---|---|---|---|
| Eliquis Coverage | No outpatient prescription coverage. Covered only during inpatient hospital stays. | Yes, typically covered on a higher formulary tier. | Yes, if the plan includes drug benefits and Eliquis is on the formulary. |
| Monthly Premium | No premium for Part A (for most); Part B premium applies. | A separate monthly premium is required. | The premium varies by plan and may include drug coverage costs. |
| Annual Deductible | Not applicable to outpatient prescriptions. | An annual deductible must be met before coverage begins. | An annual drug deductible may apply, varying by plan. |
| Patient Cost | 100% of retail cost (approximately $606/month list price as of 2025). | Copayment or coinsurance after deductible is met, based on plan and coverage stage. | Copayment or coinsurance after deductible is met, based on plan and coverage stage. |
| Restrictions | N/A | Potential prior authorization or step therapy requirements. | Potential prior authorization or step therapy requirements. |
How to Reduce Your Eliquis Costs
Several strategies can help lower your Eliquis costs with Medicare:
- Review Formularies: Compare plan formularies to find coverage with the most favorable terms before enrolling.
- Extra Help Program: This federal program assists those with limited income in paying for Part D costs, potentially reducing Eliquis costs significantly.
- Pharmacy Comparisons: Check prices at different pharmacies, as costs can vary even with coverage. Using your plan's preferred pharmacy may also lower costs.
- Inflation Reduction Act: Upcoming changes include government price negotiations for Eliquis starting in 2026 and a $2,000 annual out-of-pocket cap for Part D in 2025.
- Patient Assistance: While Medicare beneficiaries can't use manufacturer copay cards, other patient assistance programs might be available.
Conclusion
The belief that Medicare doesn't cover Eliquis is inaccurate. Most beneficiaries can get coverage through Medicare Part D or a Medicare Advantage plan with drug benefits. The key is understanding that Original Medicare doesn't cover outpatient prescriptions. Costs are influenced by plan specifics like formulary tiers and deductibles. By exploring plan options, government assistance like Extra Help, and being aware of future changes from the Inflation Reduction Act, beneficiaries can manage Eliquis costs and access this important medication. For more details, consult the official Medicare website.
