Does Quartz Health Solutions Cover Eliquis?

What Is Eliquis and Why Does Coverage Matter?

Eliquis (apixaban) is an oral anticoagulant approved by the FDA for reducing stroke risk in non-valvular atrial fibrillation, treating deep vein thrombosis (DVT), treating pulmonary embolism (PE), and preventing recurrent DVT and PE after initial therapy. The FDA's prescribing information for apixaban lists these four indications with specific dose regimens ranging from 2.5 mg twice daily to 10 mg twice daily depending on the clinical context. [1]

Clinical Importance of Uninterrupted Therapy

Atrial fibrillation affects roughly 6.1 million Americans, according to CDC surveillance data, and stroke risk in untreated AF is five times higher than in patients without the arrhythmia. [2] Stopping anticoagulation abruptly can precipitate rebound thrombosis. That clinical reality makes formulary access, not just clinical appropriateness, a direct patient-safety issue.

The ARISTOTLE trial (N=18,201) compared apixaban 5 mg twice daily with warfarin in patients with AF. Apixaban reduced stroke or systemic embolism by 21% (hazard ratio 0.79, 95% CI 0.66 to 0.95, P<0.001) and reduced major bleeding by 31% (hazard ratio 0.69, 95% CI 0.60 to 0.80, P<0.001). The full ARISTOTLE results are published in the New England Journal of Medicine. [3] Those outcome data are precisely why cardiologists and neurologists fight hard for formulary access when a payer initially declines coverage.

Where Eliquis Sits in Guideline Recommendations

The 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation guideline states: "In patients with AF and elevated stroke risk who are candidates for anticoagulation, a non-vitamin K antagonist oral anticoagulant (NOAC) is recommended in preference to warfarin (Class I, Level of Evidence A)." See the full guideline at the Journal of the American College of Cardiology. [4] Apixaban is one of four NOACs named in that Class I recommendation.

How Quartz Health Solutions Structures Its Formulary

Quartz Health Solutions is a Wisconsin-based nonprofit insurer offering commercial, Medicare Advantage, and Marketplace plans primarily across Wisconsin, Iowa, Minnesota, and Illinois. Its drug formulary follows a tiered cost-sharing model standard across most regional Blue Cross affiliates and co-op health plans.

Typical Tier Placement for Eliquis

On most Quartz commercial plan formularies reviewed during 2024, Eliquis appears at Tier 3 (preferred brand) or Tier 4 (non-preferred brand), depending on the specific group contract. Tier placement directly determines your copay or coinsurance:

• Tier 3 (preferred brand): Copays typically range from $45, $75 per 30-day fill at retail.
• Tier 4 (non-preferred brand): Copays typically range from $90, $150 per 30-day fill, or 30 to 40% coinsurance after deductible.

These figures are representative of common Quartz commercial plan structures and should be verified against your own Summary of Benefits and Coverage (SBC) document, which Quartz is required to provide under 45 CFR §147.200. Your SBC lists your specific drug tier copays.

Prior Authorization Criteria

Prior authorization (PA) is required for Eliquis on most Quartz plans. Typical PA criteria align with those published by comparable regional health plans and include:

1. A confirmed diagnosis of non-valvular AF, DVT, PE, or hip/knee replacement surgery.
2. A completed PA request form submitted by the prescribing provider.
3. Documentation that the patient is not a candidate for warfarin, or that warfarin was trialed and failed (depending on the plan's step-therapy protocol).

The FDA's 2023 apixaban label provides the clinical criteria your prescriber will reference when submitting the PA. [1]

Step Therapy Requirements

Some Quartz employer-group plans include a step-therapy requirement: the patient must try warfarin for 60 to 90 days before Eliquis will be approved without a medical exemption. Wisconsin Act 14 (Wis. Stat. §632.895(16m)), enacted in 2018, limits step-therapy requirements and creates a right to override when the prescriber attests that the required drug is clinically contraindicated or has already failed. Your prescriber can invoke this override in the PA submission.

How to Check Your Specific Quartz Plan's Eliquis Coverage

Getting a definitive answer takes about 10 minutes. Three paths exist.

Path 1: Quartz Online Formulary Tool

Log in to your Quartz member portal at quartz.org and manage to "Prescription Drug Coverage" or "Drug List." Enter "apixaban" or "Eliquis" in the search bar. The tool shows your tier, PA requirements, quantity limits, and mail-order options for your specific plan year.

Path 2: Call Member Services

Call Quartz Member Services at 1-800-362-3310 (TTY: 711). Ask the representative specifically: What tier is Eliquis on my plan? Is prior authorization required? Is step therapy required? Does my deductible apply before copays begin? Having your member ID and your prescriber's NPI number ready speeds the call.

Path 3: Ask Your Pharmacy

Your pharmacist can run a test claim before you pay. This shows the exact cost-sharing your plan assigns. It also reveals whether a PA hold is in place, which triggers a faster conversation with your prescriber's office.

What to Do If Quartz Denies Eliquis Coverage

Denial is not the end. A structured appeals process exists, and CMS guidance on Medicare Part D appeals provides a useful framework even for commercial plan members to understand the sequence. [5]

Step 1: Understand the Denial Reason

The Explanation of Benefits (EOB) or denial letter must state the specific reason. Common reasons include:

• PA not yet submitted or incomplete.
• Step-therapy criteria not met.
• Quantity limit exceeded.
• Drug not covered under this plan (rare for Eliquis given its guideline status).

Step 2: Submit a PA or Exception Request

Your prescriber submits a PA with supporting clinical documentation. For AF, this includes the CHA2DS2-VASc score, prior anticoagulation history, any bleeding events, and the clinical rationale for preferring apixaban over warfarin. The ACC/AHA 2023 AF guideline provides the evidence base your prescriber cites. [4]

A practical framework for prescribers submitting Eliquis PAs to Quartz:

| PA Component | What to Include | |---|---| | Diagnosis | ICD-10 code (e.g., I48.0 for paroxysmal AF) | | CHA2DS2-VASc score | Numeric score plus component list | | Prior warfarin trial | Duration, INR control rate, reason for failure (if applicable) | | Contraindication to warfarin | Labile INR, drug interactions, patient preference with documented counseling | | Guideline reference | ACC/AHA 2023 Class I NOAC recommendation | | Step-therapy override | Wisconsin Act 14 attestation if required |

Step 3: File a Formal Internal Appeal

If the PA is denied, you have the right to a formal internal appeal. Under Wisconsin insurance law (Wis. Stat. §632.83), you typically have 60 days from the denial notice to file. The appeal must be decided within 30 days for non-urgent requests and 72 hours for urgent/expedited requests.

Step 4: External Review

If the internal appeal fails, Wisconsin requires external independent review for adverse benefit determinations involving medical necessity. The Wisconsin Office of the Commissioner of Insurance oversees this process. An independent review organization (IRO) then renders a binding decision.

Cost-Reduction Options While Awaiting Coverage Approval

Bristol-Myers Squibb / Pfizer Eliquis Copay Card

Bristol-Myers Squibb and Pfizer jointly market Eliquis and offer a copay assistance card for commercially insured patients. As of 2024, eligible patients pay as little as $10 per 30-day fill for up to 24 months. The program is available at eliquis.bmscustomerconnect.com. Medicare and Medicaid patients do not qualify for this manufacturer card but may qualify for patient assistance programs.

Patient Assistance Program (PAP)

Both BMS and Pfizer operate patient assistance programs for uninsured or underinsured patients. Income-based eligibility typically falls at or below 400% of the federal poverty level. The NeedyMeds database aggregates PAP information and can match patients to programs within minutes.

Generic Apixaban

The FDA approved the first generic apixaban products in 2023. FDA's generic drug approval database lists the approved manufacturers. [6] Generic entry typically reduces retail price by 70 to 85% over 24 to 36 months as competition increases. If your Quartz plan places generic apixaban at a lower tier than the branded product, this may be the fastest cost-reduction path. Ask your pharmacist whether generic substitution is available and permitted under your plan.

90-Day Mail-Order Supply

Most Quartz plans offer a lower per-unit cost for 90-day mail-order fills compared to 30-day retail fills. A Tier 3 drug with a $60 retail copay might carry a $120, $135 mail-order copay for a 90-day supply, saving roughly $45 per quarter.

Eliquis on Quartz Medicare Advantage Plans

Medicare Advantage members face a different coverage structure than commercial plan members.

Part D Formulary Requirements

Medicare Advantage Prescription Drug (MA-PD) plans must cover all drugs in six protected classes, but anticoagulants are not in those six classes. Eliquis coverage on Quartz Medicare Advantage plans therefore depends on the specific plan's formulary. CMS Medicare Prescription Drug Benefit Manual outlines the formulary standards MA-PD plans must meet. [7]

2025 Medicare Out-of-Pocket Cap

The Inflation Reduction Act (IRA) capped Medicare Part D out-of-pocket drug costs at $2,000 per year starting January 1, 2025, eliminating the previous coverage gap ("donut hole"). CMS confirmation of the $2,000 cap is published at cms.gov. [8] For Medicare members on Eliquis who previously spent $3,000, $5,000 annually on drug costs, this cap represents a substantial reduction in total exposure.

Low-Income Subsidy (Extra Help)

Medicare beneficiaries with limited income and resources may qualify for the Part D Low Income Subsidy (Extra Help), which reduces or eliminates Part D premiums, deductibles, and copays. In 2024, full Extra Help beneficiaries paid no more than $4.50 per generic fill and $11.20 per brand-name fill. The SSA Extra Help program page provides eligibility criteria. [9]

Warfarin vs. Eliquis: Why Prescribers Push Back Against Step Therapy

Understanding the clinical stakes helps explain why PA and appeals processes are worth pursuing.

Outcomes Data Favoring Apixaban

The ARISTOTLE trial (N=18,201) showed apixaban reduced the primary endpoint of stroke or systemic embolism at a rate of 1.27% per year versus 1.60% per year for warfarin (hazard ratio 0.79, P<0.001). [3] More relevant to step-therapy debates, apixaban reduced intracranial hemorrhage by 58% compared with warfarin (0.33% vs. 0.80% per year, P<0.001). Intracranial hemorrhage is often fatal; this safety difference carries substantial clinical weight.

Monitoring Burden and Time in Therapeutic Range

Warfarin requires routine INR monitoring, typically every 4 weeks once stable. Patients with labile INRs spend a smaller proportion of time in the therapeutic range (TTR), reducing effectiveness. A 2014 analysis published in Circulation found that patients with TTR below 65% derived diminishing net clinical benefit from warfarin, with the benefit/risk ratio approaching parity with no treatment in very low TTR populations. [10] Apixaban provides fixed, predictable pharmacokinetics without monitoring.

Guideline Statement on Step Therapy

The ACC/AHA 2023 AF guideline explicitly states: "Initiating therapy with a vitamin K antagonist (warfarin) before a NOAC is not recommended when a NOAC is appropriate (Class III: No Benefit, Level of Evidence B-R)." [4] This Class III statement gives prescribers direct guideline language to cite when requesting a step-therapy override from Quartz or any other payer.

Quartz Coverage for Related Anticoagulants

If Eliquis remains inaccessible, two comparable NOACs may have more favorable tier placement on your specific Quartz plan.

Xarelto (Rivaroxaban)

Rivaroxaban is approved for the same AF stroke-prevention and VTE treatment indications as apixaban. The ROCKET-AF trial (N=14,264) showed rivaroxaban was non-inferior to warfarin for stroke prevention in AF (hazard ratio 0.88, 95% CI 0.74 to 1.03). [11] On some Quartz formularies, rivaroxaban sits at Tier 3 while apixaban sits at Tier 4, making a formulary exception less necessary if rivaroxaban is clinically appropriate.

Pradaxa (Dabigatran)

Dabigatran was the first approved NOAC in the United States. The RE-LY trial (N=18,113) showed dabigatran 150 mg twice daily reduced stroke by 34% versus warfarin (hazard ratio 0.66, P<0.001) in AF patients. [12] Some patients cannot use dabigatran due to dyspepsia or renal constraints (dose adjustment required when CrCl drops to 15 to 30 mL/min), but it may be a viable alternative if apixaban access is delayed.

These are clinical decisions that require a conversation with your prescriber. Switching anticoagulants without medical supervision is not appropriate.

Documentation Your Prescriber Should Keep on File

A prescriber who anticipates a PA or appeal for Eliquis should document the following at the time of prescribing:

• CHA2DS2-VASc score and individual risk components.
• Reason for NOAC preference over warfarin (monitoring burden, labile INR history, patient preference with counseling documented, drug interactions, bleeding history).
• Prior anticoagulation history, including any prior warfarin trial with INR logs if available.
• Renal function (CrCl via Cockcroft-Gault), hepatic function, and weight at time of prescribing, since these affect dosing decisions under the FDA-approved label. [1]
• A copy of the ACC/AHA 2023 Class I NOAC recommendation attached to the PA submission.

This documentation package reduces PA turnaround time and strengthens any subsequent appeal.

Key Contacts and Resources

• Quartz Member Services: 1-800-362-3310 (TTY: 711), Monday through Friday, 8 a.m. To 5 p.m. CT.
• Eliquis Copay Card: Available through BMS Customer Connect at bms.com/patient-and-caregivers/patient-support/copay-assistance.html.
• NeedyMeds PAP Search: needymeds.org.
• Wisconsin OCI External Review: oci.wi.gov.
• CMS Medicare Plan Finder: medicare.gov/plan-compare.
• FDA Generic Drug Database: accessdata.fda.gov/scripts/cder/daf/index.cfm.