Does SelectHealth Cover Eliquis? A Complete Coverage Guide

At a glance
- Drug name / Eliquis (apixaban), oral Factor Xa inhibitor
- Typical SelectHealth tier / Tier 3 (preferred brand) or Tier 4 (non-preferred brand) depending on plan
- Prior authorization / Required for most indications on most SelectHealth plans
- Common indications covered / Non-valvular atrial fibrillation, DVT treatment, DVT/PE prophylaxis
- Typical brand copay range / $45, $110 per 30-day supply at Tier 3; higher at Tier 4
- Generic availability / No FDA-approved generic apixaban as of early 2025
- Manufacturer savings / Bristol-Myers Squibb/Pfizer offers the Eliquis 360 Support program (as low as $10/month for eligible commercially insured patients)
- Step therapy / Some SelectHealth plans require a trial of warfarin before approving Eliquis
- Appeal rights / Members can appeal prior authorization denials within 180 days of the denial date
- Medicare Part D / Eliquis coverage and cost-sharing vary by SelectHealth Medicare Advantage plan; Extra Help may reduce costs significantly
What Is Eliquis and Why Does Coverage Matter?
Eliquis (apixaban) is an oral, direct Factor Xa inhibitor approved by the FDA for stroke prevention in non-valvular atrial fibrillation, treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), reduction of recurrent DVT and PE, and prophylaxis of DVT following hip or knee replacement surgery [1]. It is a branded medication with no FDA-approved generic substitute available in the United States as of early 2025 [2].
Because apixaban carries a list price exceeding $550 per 30-day supply, insurance tier placement determines whether most patients can afford long-term anticoagulation therapy. The ARISTOTLE trial (N=18,201) demonstrated that apixaban reduced stroke or systemic embolism by 21% relative to warfarin and all-cause mortality by 11%, establishing apixaban as a first-line anticoagulant across cardiology guidelines [3]. The American Heart Association and American College of Cardiology guidelines for atrial fibrillation management recommend direct oral anticoagulants (DOACs), including apixaban, as preferred over warfarin for most patients with non-valvular AF [4].
Given that guideline-preferred therapy can cost patients hundreds of dollars per month without insurance, understanding exactly how SelectHealth structures its formulary is a practical clinical and financial question.
How Formulary Tiers Work
Most SelectHealth commercial plans use a five-tier formulary structure. Tier 1 covers generic drugs at the lowest copay. Tier 2 covers preferred generics or low-cost brands. Tier 3 is preferred brand-name drugs. Tier 4 is non-preferred brands. Tier 5 is specialty drugs.
Eliquis most often lands on Tier 3 or Tier 4 across SelectHealth's commercial product lines, which means member cost-sharing of roughly $45 to $110 per 30-day fill at Tier 3 before the deductible is met, and potentially more at Tier 4.
Why Prior Authorization Is Common
SelectHealth, like most major insurers, uses prior authorization (PA) for brand-name anticoagulants to confirm the diagnosis meets FDA-approved indications and that prescribing aligns with clinical guidelines [5]. The FDA label for apixaban specifies distinct dosing for AF (5 mg twice daily, or 2.5 mg twice daily in patients meeting two of three criteria: age 80 or older, weight 60 kg or less, or serum creatinine 1.5 mg/dL or higher) and for VTE treatment (10 mg twice daily for 7 days, then 5 mg twice daily) [1]. PA requirements help plans verify the prescribed dose matches the labeled indication.
How to Check If Your Specific SelectHealth Plan Covers Eliquis
SelectHealth publishes its formulary documents online, and the coverage status of Eliquis can change with each plan year. The fastest verification methods are:
Step 1, Use the SelectHealth Online Drug Search
SelectHealth's website hosts a searchable formulary tool. Enter "apixaban" or "Eliquis" alongside your plan name and plan year to see the current tier assignment, any quantity limits, and whether prior authorization applies. Formulary status is updated each January 1 and may change mid-year through a notice period.
Step 2, Call Member Services
The phone number on the back of your SelectHealth ID card connects you to a pharmacy benefits representative who can confirm tier placement, copay amounts at your current deductible stage, and any step-therapy requirements for your specific benefit design.
Step 3, Ask Your Pharmacist to Run a Test Claim
A pharmacist can run a test claim before you pick up the medication. This shows the exact cost-sharing the plan will apply, including whether your deductible has been met and whether a quantity limit exception applies.
Step 4, Review Your Summary of Benefits and Coverage
The Summary of Benefits and Coverage (SBC) document, which federal law requires plans to provide, states cost-sharing tiers in plain language. The SBC does not list individual drugs, but it shows the copay or coinsurance percentage for each tier, letting you calculate what Tier 3 or Tier 4 means in dollar terms [6].
SelectHealth Medicare Advantage and Eliquis Coverage
SelectHealth offers Medicare Advantage plans in Utah, Idaho, and Nevada. Coverage of Eliquis under these plans is governed by the Medicare Part D formulary rules administered by CMS [7].
Part D Formulary Placement
Under Medicare Part D, Eliquis is typically placed in the preferred or non-preferred brand tier. CMS requires that all Part D formularies include anticoagulants in the protected drug class category, which means plans must cover all or substantially all anticoagulants [8]. This protected-class designation gives apixaban stronger formulary inclusion than most non-protected drugs.
Cost in the Coverage Gap
Before 2025, Medicare Part D members who reached the coverage gap ("donut hole") paid 25% of the cost of brand-name drugs. The Inflation Reduction Act of 2022 eliminated the coverage gap effective January 1, 2025, capping annual out-of-pocket drug spending at $2,000 for Part D enrollees [9]. For SelectHealth Medicare Advantage members on Eliquis, this cap significantly reduces maximum annual exposure compared to prior years.
Extra Help / Low Income Subsidy
Medicare beneficiaries with limited income and resources may qualify for Extra Help (also called the Low Income Subsidy, or LIS), which reduces Part D premiums and cost-sharing to nominal levels [10]. SelectHealth Medicare Advantage members who qualify for Extra Help may pay $0 to $11.20 per month for Eliquis, depending on LIS level.
Prior Authorization for Eliquis on SelectHealth: What You Need to Know
Prior authorization denials for Eliquis are among the most common pharmacy benefit issues for SelectHealth members on anticoagulation therapy. The process, documentation requirements, and appeal rights follow a defined structure.
Common PA Criteria SelectHealth Uses
SelectHealth PA criteria for Eliquis typically require documentation of:
- Confirmed diagnosis of non-valvular AF, DVT, PE, or post-surgical VTE prophylaxis (matching FDA-labeled indications)
- Relevant lab values, particularly creatinine and weight for dose verification
- Prescriber attestation that the patient has a contraindication to, or has failed, warfarin therapy (on plans with step-therapy requirements)
- CHA2DS2-VASc score for AF patients, per AHA/ACC guideline thresholds [4]
The AHA/ACC 2023 AF guideline states: "For patients with AF and CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulation is recommended to reduce the risk of stroke and thromboembolism (Class I, Level A)." [4]
Step Therapy and Warfarin Requirements
Some SelectHealth commercial plans include a step-therapy protocol that requires a documented trial of warfarin (usually 90 days) before Eliquis is approved. Step-therapy laws in Utah and other states where SelectHealth operates provide patients with a right to a step-therapy exemption if:
- The required first-step drug is contraindicated or clinically inappropriate.
- The patient previously tried and failed the required drug.
- A peer-reviewed clinical study supports the exception.
Your prescribing physician must submit clinical documentation to support the exception request. The RE-LY trial (N=18,113), ROCKET AF trial (N=14,264), and ARISTOTLE trial (N=18,201) all provide level A evidence supporting DOACs over warfarin in patients where warfarin is difficult to manage or where bleeding risk is a concern [3, 11, 12].
Appealing a Denial
Federal law gives SelectHealth members the right to appeal PA denials through an internal appeal and, if that fails, through an external review by an independent organization [13]. For Medicare Advantage members, the process includes:
- Redetermination by SelectHealth (60-day timeframe for standard; 72 hours for expedited)
- Reconsideration by a Qualified Independent Contractor
- Administrative Law Judge hearing if the amount in controversy exceeds $180
- Medicare Appeals Council review
- Federal District Court review
Commercial plan members follow a similar internal and external appeal ladder under state insurance law and the ACA's external review provisions [13].
What Eliquis Costs Without Insurance or When SelectHealth Denies Coverage
The retail list price of Eliquis is approximately $550 to $600 for a 30-day supply of 5 mg tablets (twice-daily dosing), making uninsured access difficult for long-term use [2].
Bristol-Myers Squibb and Pfizer Eliquis 360 Support Program
Bristol-Myers Squibb and Pfizer, the co-manufacturers of Eliquis, operate the Eliquis 360 Support savings program. Commercially insured patients who meet eligibility criteria may pay as little as $10 per month. Medicare patients are not eligible for this manufacturer copay card, but may access a separate patient assistance program based on income [2].
To enroll, visit the Eliquis official website or call 1-855-ELIQUIS. The prescribing office can also initiate enrollment on behalf of the patient.
GoodRx and Discount Programs
GoodRx and similar prescription discount services negotiate cash-pay prices with pharmacies. Prices vary by pharmacy and location, but discount prices for a 30-day supply of Eliquis 5 mg can range from $300 to $450, which is lower than the retail list price but still substantial. These discount prices cannot be combined with SelectHealth insurance benefits on the same fill [14].
90-Day Mail Order Dispensing
SelectHealth, like most commercial insurers, offers lower per-unit cost-sharing for 90-day mail-order fills compared to three sequential 30-day retail fills. If Eliquis is covered on your plan, switching to mail order may save $30 to $60 per quarter depending on your tier.
Alternatives to Eliquis That SelectHealth May Prefer
If Eliquis is placed on a high-cost tier or denied through prior authorization, your physician may discuss whether another anticoagulant is appropriate for your clinical situation.
Warfarin (Coumadin)
Warfarin is a Tier 1 generic on nearly all SelectHealth formularies, typically costing $4 to $10 per 30-day supply. It requires regular INR monitoring and has more drug and food interactions than apixaban. The ARISTOTLE trial showed apixaban produced significantly fewer major bleeds (2.13% per year vs. 3.09% per year with warfarin, P<0.001) [3]. For patients who tolerate INR monitoring and maintain stable anticoagulation, warfarin remains a clinically appropriate, lower-cost option.
Rivaroxaban (Xarelto)
Rivaroxaban is another oral Factor Xa inhibitor. Its tier placement on SelectHealth formularies may differ from apixaban, and in some plan years it is placed on a lower tier. The ROCKET AF trial (N=14,264) demonstrated rivaroxaban was non-inferior to warfarin for stroke prevention in AF (P<0.001 for non-inferiority) [11]. Once-daily dosing may benefit adherence in some patients.
Dabigatran (Pradaxa)
Dabigatran is a direct thrombin inhibitor rather than a Factor Xa inhibitor. The RE-LY trial (N=18,113) showed dabigatran 150 mg twice daily was superior to warfarin for stroke prevention in AF (relative risk 0.66, 95% CI 0.53 to 0.82, P<0.001) [12]. SelectHealth formulary tier placement for dabigatran may differ from apixaban.
Edoxaban (Savaysa)
Edoxaban is a Factor Xa inhibitor approved for AF and VTE. The ENGAGE AF-TIMI 48 trial (N=21,105) showed edoxaban was non-inferior to warfarin for stroke prevention and produced significantly fewer major bleeding events (P<0.001) [15]. Edoxaban's tier on SelectHealth formularies varies by plan year.
A conversation with your cardiologist or hematologist about which anticoagulant best fits your clinical profile and formulary tier is the appropriate next step when cost is a barrier.
Clinical Indications Where SelectHealth Coverage for Eliquis Is Most Straightforward
Coverage approval is more predictable when the indication clearly matches the FDA label and the documentation is complete.
Non-Valvular Atrial Fibrillation
AF is the most common indication for apixaban. FDA-approved for stroke reduction in non-valvular AF since 2012, apixaban has broad guideline support. SelectHealth typically approves PA requests for AF when the CHA2DS2-VASc score meets the AHA/ACC threshold and the dose matches the label [4].
DVT and PE Treatment
Apixaban received FDA approval for DVT and PE treatment in 2012 and for secondary prevention in 2013 [1]. The AMPLIFY trial (N=5,395) demonstrated apixaban was non-inferior to conventional therapy (enoxaparin plus warfarin) for VTE treatment and produced 69% fewer major bleeds (P<0.001) [16]. These data support PA approvals when the chart documents confirmed thrombosis.
Post-Surgical VTE Prophylaxis
FDA approval for DVT prophylaxis following hip and knee replacement is supported by the ADVANCE-2 (N=3,057) and ADVANCE-3 (N=5,407) trials, which showed apixaban significantly reduced VTE events compared to enoxaparin [17, 18]. Coverage for this shorter-duration indication (10 to 35 days) is generally less contested in PA reviews than long-term AF therapy.
Documentation Tips for Prescribers Submitting PA Requests to SelectHealth
When submitting a PA for Eliquis to SelectHealth, the completeness of the clinical package directly affects the approval speed and success rate.
Include in the PA package:
- ICD-10 code matching the FDA-labeled indication (I48.x for AF; I82.x for DVT; I26.x for PE)
- Current medication list showing allergy or intolerance to warfarin if claiming contraindication
- INR records if claiming warfarin failure (typically INR out of range more than 40% of time, known as time-in-therapeutic range below 60%)
- Renal function labs (serum creatinine, eGFR) to confirm apixaban is appropriate; the FDA label advises caution in severe renal impairment (CrCl <15 mL/min) [1]
- Body weight if dose-reduction criteria apply
- Echocardiogram or imaging report confirming non-valvular AF (ruling out mechanical valve or rheumatic mitral stenosis, which are excluded from the DOAC label)
The American College of Cardiology's DOAC prescribing guidance notes that time-in-therapeutic range below 65 to 70% with warfarin represents a clinically appropriate threshold for transitioning to a DOAC [19].
How SelectHealth Handles Eliquis for Special Populations
Patients with Chronic Kidney Disease
Severe chronic kidney disease (CKD) complicates anticoagulant selection. The FDA label for apixaban does not require dose adjustment solely for renal impairment but does specify the 2.5 mg twice-daily dose when patients meet two of three dose-reduction criteria (age 80 or older, weight 60 kg or less, serum creatinine 1.5 mg/dL or higher) [1]. SelectHealth PA reviewers may request renal function documentation to confirm dose appropriateness. Patients with end-stage renal disease on dialysis present a complex case; warfarin or careful DOAC selection guided by nephrology consultation is typically recommended [20].
Patients with Cancer-Associated Thrombosis
Anticoagulation for cancer-associated thrombosis has evolved. The ADAM VTE trial (N=300) and SELECT-D trial (N=406) support the use of apixaban and rivaroxaban, respectively, over low-molecular-weight heparin in many cancer patients with VTE [21, 22]. SelectHealth PA for cancer-associated VTE may require oncology documentation confirming active malignancy and the specific cancer type, as patients with gastrointestinal or genitourinary cancers carry higher GI bleeding risk with DOACs [23].
Pediatric Patients
Apixaban received FDA approval for pediatric VTE treatment and prophylaxis in patients from birth to less than 18 years in 2024, based on the SAXOPHONE and CLARINET-PED trials [1]. SelectHealth pediatric formulary coverage for apixaban is evolving; PA approval for pediatric indications may require pediatric hematology consultation documentation.
Frequently asked questions
›Does SelectHealth cover Eliquis?
›What tier is Eliquis on SelectHealth plans?
›Does SelectHealth require prior authorization for Eliquis?
›What happens if SelectHealth denies my Eliquis prior authorization?
›Does SelectHealth Medicare Advantage cover Eliquis?
›Can I use the Eliquis manufacturer savings card with SelectHealth?
›Does SelectHealth require step therapy before covering Eliquis?
›Is there a generic version of Eliquis that SelectHealth covers at a lower tier?
›How do I find the exact Eliquis copay on my SelectHealth plan?
›What clinical indications does SelectHealth typically approve Eliquis for?
›What should my doctor include in a SelectHealth Eliquis PA request?
References
- Bristol-Myers Squibb/Pfizer. Eliquis (apixaban) Prescribing Information. U.S. Food and Drug Administration. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/202155s030lbl.pdf
- U.S. Food and Drug Administration. Drug Approvals and Databases. Available at: https://www.fda.gov/drugs/drug-approvals-and-databases
- Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation (ARISTOTLE). N Engl J Med. 2011;365:981-992. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1107039
- Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for Diagnosis and Management of Atrial Fibrillation. J Am Coll Cardiol. 2024;83(1):109-279. Available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001193
- Centers for Medicare and Medicaid Services. Medicare Prescription Drug Benefit Manual, Chapter 6: Part D Drugs and Formulary Requirements. Available at: https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/downloads/chapter6.pdf
- U.S. Department of Labor. Summary of Benefits and Coverage. Available at: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits-and-coverage
- Centers for Medicare and Medicaid Services. Medicare Advantage and Part D. Available at: https://www.cms.gov/medicare/health-drug-plans/medicareadvantage
- Centers for Medicare and Medicaid Services. Protected Drug Classes Under Part D. Available at: https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra
- Inflation Reduction Act: Medicare Part D Redesign. Available at: https://www.cms.gov/inflation-reduction-act-and-medicare
- Social Security Administration. Extra Help with Medicare Prescription Drug Plan Costs. Available at: https://www.ssa.gov/benefits/medicare/prescriptionhelp.html
- Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation (ROCKET AF). N Engl J Med. 2011;365:883-891. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1009638
- Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation (RE-LY). N Engl J Med. 2009;361:1139-1151. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa0905561
- U.S. Department of Health and Human Services. External Review Rights Under the ACA. Available at: https://www.healthcare.gov/appeal-insurance-company-decisions/external-review/
- National Academies of Sciences, Engineering, and Medicine. Prescription Drug Pricing: A Primer. Available at: https://www.ncbi.nlm.nih.gov/books/NBK547548/
- Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus Warfarin in Patients with Atrial Fibrillation (ENGAGE AF-TIMI 48). N Engl J Med. 2013;369:2093-2104. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1310907
- Agnelli G, Buller HR, Cohen A, et al. Oral Apixaban for the Treatment of Acute Venous Thromboembolism (AMPLIFY). N Engl J Med. 2013;369:799-808. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1302507
- Lassen MR, Raskob GE, Gallus A, et al. Apixaban versus Enoxaparin for Thromboprophylaxis after Knee Replacement (ADVANCE-2). Lancet. 2010;375:807-815. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62125-5/fulltext
- Lassen MR, Gallus A, Raskob GE, et al. Apixaban versus Enoxaparin for Thromboprophylaxis after Hip Replacement (ADVANCE-3). N Engl J Med. 2010;363:2487-2498. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1006885
- American College of Cardiology. DOAC Prescribing Guidance for Atrial Fibrillation. Available at: https://www.acc.org/latest-in-cardiology/articles/2021/07/08/14/42/doac-prescribing-guidance
- Pokorney SD, Chertow GM, Bhatt DL, et al. Apixaban for Patients with Atrial Fibrillation on Hemodialysis (RENAL-AF). Circulation. 2022;145:1258-1261. Available at: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.121.055933
- McBane RD, Wysokinski WE, Le-Rademacher JG, et al. Apixaban and Dalteparin in Active Malignancy-Associated Venous Thromboembolism (ADAM VTE). J Thromb Haemost. 2020;18:411-421. Available at: https://pubmed.ncbi.nlm.nih.gov/31630484/
- Young AM, Marshall A, Thirlwall J, et al. Comparison of an Oral