Does SummaCare Cover Eliquis?

What Is Eliquis and Why Does Coverage Matter?

Eliquis (apixaban) is an oral anticoagulant that works by directly blocking Factor Xa in the coagulation cascade. The FDA granted initial approval in December 2012 for reducing stroke risk in nonvalvular atrial fibrillation, and later expanded labeling covers treatment and secondary prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as prophylaxis after elective hip or knee replacement surgery. 1

Why Apixaban Is Prescribed So Widely

Atrial fibrillation affects an estimated 6 million Americans, and that number is projected to double by 2050 according to CDC surveillance data. 2 Stroke risk in untreated AF is roughly five times higher than in people with normal sinus rhythm, which means long-term anticoagulation is a standard of care for most patients with AF and a CHA2DS2-VASc score of 2 or higher in men and 3 or higher in women. 3

Apixaban became the dominant oral anticoagulant in that setting partly because of its efficacy data. In the ARISTOTLE trial (N=18,201), apixaban reduced the rate of stroke or systemic embolism by 21% compared with dose-adjusted warfarin (1.27% vs. 1.60% per year; P<0.001) and cut major bleeding by 31% (2.13% vs. 3.09% per year; P<0.001). 4 Those numbers represent a meaningful safety advantage that guidelines now reflect.

The 2023 ACC/AHA atrial fibrillation guideline gives a Class I, Level of Evidence A recommendation for non-vitamin K oral anticoagulants (NOACs) such as apixaban over warfarin in patients with nonvalvular AF who are candidates for anticoagulation. 3 That recommendation drives prescribing volume, which in turn makes coverage questions about apixaban among the most common insurance inquiries cardiologists and primary care providers deal with every week.

The Cost Problem

Without insurance or a discount program, a 60-tablet supply of Eliquis 5 mg costs approximately $550, $600 at major retail pharmacies in 2025. Because no FDA-approved generic exists for apixaban as of mid-2025, patients cannot simply switch to a lower-cost equivalent the way they can with older agents like warfarin or rivaroxaban competitors. That reality makes accurate knowledge of your plan's coverage terms genuinely consequential for adherence: research published in JAMA Internal Medicine found that patients prescribed a high-cost anticoagulant who faced out-of-pocket costs above $50 per month were significantly more likely to discontinue therapy within 12 months. 5

How SummaCare Plans Are Structured

SummaCare is a regional health plan based in Akron, Ohio, operating primarily in northeastern Ohio. It offers Medicare Advantage (Part C) plans, Medicare Supplement (Medigap) plans, and some employer-sponsored commercial products. Understanding which product category you hold matters before interpreting any formulary information.

Medicare Advantage vs. Commercial Coverage

Medicare Advantage plans include Part D prescription drug coverage and must publish an annual formulary. The formulary is a tiered list of covered drugs, and each tier carries a specific copay or coinsurance rate set for the plan year. SummaCare files its Medicare Advantage formularies with the Centers for Medicare and Medicaid Services (CMS) each year, and the published drug list is legally binding for that benefit period. 6

Commercial or employer-sponsored plans follow different rules. The formulary is negotiated between SummaCare and the employer group, so two employees at different companies could have meaningfully different tier placements and cost-sharing for the same drug.

Medicare Supplement (Medigap) plans sold by SummaCare do not include Part D drug coverage at all. If you hold only a Medigap policy, you need a separate Part D stand-alone plan to get prescription drug benefits for Eliquis.

How Formulary Tiers Work

Most SummaCare Medicare Advantage plans use a four- or five-tier structure:

| Tier | Category | Typical Cost-Sharing | |------|----------|----------------------| | 1 | Preferred generics | $0, $5 copay | | 2 | Non-preferred generics | $10, $20 copay | | 3 | Preferred brand | $40, $50 copay | | 4 | Non-preferred brand | $95, $105 copay or 25 to 33% coinsurance | | 5 | Specialty | 25 to 33% coinsurance, often $200+ per fill |

Apixaban, as a branded drug with no generic competitor, typically lands on Tier 3 or Tier 4 depending on the specific plan year formulary. Some plans categorize it as a specialty drug, which pushes it to Tier 5 and the highest cost-sharing band. Verifying the current year's tier placement before filling a prescription prevents surprise bills at the pharmacy counter.

Does SummaCare Cover Eliquis on Its Current Formulary?

Yes, apixaban appears on SummaCare Medicare Advantage formularies, but coverage comes with conditions. The two most common restrictions are prior authorization and, in some plan variants, step therapy requirements.

Prior Authorization Requirements

Prior authorization (PA) means your prescribing physician must submit clinical documentation to SummaCare before the plan will approve coverage at the formulary tier rate. For apixaban, PA requests typically need to demonstrate:

• A confirmed diagnosis (e.g., nonvalvular AF with CHA2DS2-VASc score meeting threshold, or confirmed DVT/PE with imaging)
• Documentation of the prescriber's rationale for choosing apixaban over warfarin, particularly if cost is a barrier to warfarin monitoring
• Kidney function data, because apixaban dosing is adjusted for low body weight, elevated creatinine, and advanced age (the "two-of-three" dose reduction criteria per FDA labeling) 1

The PA approval, once granted, typically covers 12 months and must be renewed annually. Gaps in prior authorization are one of the most common reasons a pharmacy cannot process an Eliquis claim even when the patient has active insurance.

Step Therapy Clauses

Some SummaCare commercial plans include a step therapy (also called "fail first") requirement for apixaban. Step therapy means the plan will not cover apixaban until the patient has tried and documented inadequate response or intolerance to a preferred alternative, most often warfarin. Ohio law (Ohio Revised Code 3902.21) provides a step therapy override mechanism that allows a prescribing physician to request an exemption when step therapy would cause harm, be clinically contraindicated, or would delay necessary care. 7 If your prescriber believes apixaban is the appropriate first-line therapy, submitting an override request with supporting clinical documentation is a viable and legally protected pathway.

Checking the Current Formulary Directly

Formularies change every January 1, and mid-year updates are allowed under CMS rules with 60 days' notice. The only authoritative source for whether your plan covers Eliquis today is:

1. SummaCare's online formulary search tool at summacare.com (enter your plan name and look up "apixaban" or "Eliquis")
2. The Evidence of Coverage (EOC) document mailed to you each fall during open enrollment
3. Calling SummaCare member services at the number on the back of your insurance card and asking specifically: "Is apixaban (Eliquis) covered on my plan's formulary, what tier is it on, and does it require prior authorization?"

How Much Will Eliquis Cost With SummaCare Coverage?

Cost depends on tier placement, deductible status, and benefit phase for Medicare Part D enrollees.

Standard Benefit Phase Costs

Before meeting your plan's drug deductible, you pay the full negotiated rate for a Tier 3 or Tier 4 drug, which for apixaban may be $200, $400 per fill depending on the plan's negotiated price. Once past the deductible, the tier copay or coinsurance applies. At a 25% coinsurance rate on a $550 negotiated price, that is still $137.50 per 30-day fill.

Medicare Part D Redesign After the Inflation Reduction Act

Starting in 2025, the Inflation Reduction Act significantly restructures Medicare Part D cost-sharing. Out-of-pocket drug spending for Medicare Part D enrollees is now capped at $2,000 per year. Once a beneficiary reaches that cap, their cost-sharing drops to $0 for the remainder of the plan year. 8 For a patient paying $137.50 per fill, the $2,000 cap would be reached after approximately 14 to 15 months of fills, meaning some patients will hit the cap within a single plan year and pay nothing for subsequent refills.

Extra Help and Low-Income Subsidy

Medicare beneficiaries who qualify for the Low-Income Subsidy (LIS), also called Extra Help, pay a fixed copay of $0, $11.20 per fill for covered drugs regardless of tier, including Tier 4 brand drugs. Eligibility is based on income and assets; the Social Security Administration administers applications. 9 If cost is a barrier to filling apixaban, checking LIS eligibility is one of the first steps a prescriber's office or pharmacist should take.

Commercial Plan Cost-Sharing

For SummaCare commercial members, cost-sharing for a Tier 3 preferred brand is commonly a flat copay of $40, $60 per 30-day fill after the deductible. Non-preferred brand placement can mean coinsurance of 30 to 40%, which on a $550 list price approaches $165, $220 per month. Those figures vary substantially by employer contract.

Ways to Reduce Out-of-Pocket Costs for Eliquis

Several programs can reduce or eliminate out-of-pocket spending on apixaban independent of SummaCare's tier placement.

Bristol-Myers Squibb and Pfizer Co-Pay Card

The Eliquis co-pay assistance card, offered jointly by Bristol-Myers Squibb and Pfizer (the drug's co-manufacturers), can reduce monthly cost to as low as $10 per fill for commercially insured patients who meet eligibility criteria. The card is not available to Medicare or Medicaid beneficiaries. Enrollment is at bms.com or pfizer.com patient assistance pages.

Bristol-Myers Squibb Patient Assistance Program

For uninsured or underinsured patients with financial need, the BMS Access Support program may provide Eliquis at no cost. Income thresholds and documentation requirements apply. A prescriber's office social worker or patient navigator can assist with the application.

Pharmacy Discount Coupons and GoodRx

GoodRx and similar discount platforms negotiate lower cash prices at retail pharmacies. Cash-pay prices for apixaban through GoodRx have ranged from $430 to $490 for a 60-tablet supply at major chains, which is below the standard retail sticker price but still high. These discounts cannot be combined with insurance and do not count toward Medicare Part D out-of-pocket totals, so they are most useful for patients in the deductible phase of a commercial plan.

Therapeutic Alternatives With Different Tier Placement

If prior authorization is denied and cost remains prohibitive, a prescriber may consider whether an alternative oral anticoagulant sits on a more favorable tier. Warfarin, for example, is a generic on virtually every formulary at Tier 1 with minimal copay. However, warfarin requires regular INR monitoring, has a narrow therapeutic window, and carries significant drug-food interactions. The ACC/AHA guideline preference for NOACs over warfarin in nonvalvular AF is based on outcome data, not convenience alone. 3 Any therapeutic substitution decision must involve the prescribing physician and account for the individual patient's renal function, bleeding risk, and adherence profile.

Rivaroxaban (Xarelto) and dabigatran (Pradaxa) are alternative NOACs. Rivaroxaban achieved Tier 3 preferred brand status on many formularies after its own market negotiations. In the ROCKET-AF trial (N=14,264), rivaroxaban was non-inferior to warfarin for stroke prevention in AF (1.7% vs. 2.2% per year; P<0.001 for non-inferiority). 10 Whether a switch from apixaban to rivaroxaban is clinically appropriate depends on individual patient factors and must be a physician-directed decision.

How to File a Formulary Exception or Appeal With SummaCare

If SummaCare denies prior authorization for Eliquis or places it at a tier that makes it unaffordable, you have a formal right to appeal.

Step 1: Coverage Determination Request

Ask SummaCare for a formal coverage determination. For Medicare Advantage members, the plan must respond to a standard request within 72 hours (or 24 hours for urgent requests). 11

Step 2: Formulary Exception

A formulary exception asks the plan to cover a non-covered drug or cover a drug at a lower cost-sharing tier because a clinically appropriate alternative is not available. Your physician must submit a supporting statement explaining why apixaban is medically necessary and why alternatives are contraindicated or inadequate. CMS requires plans to consider these exceptions. 11

Step 3: Internal Appeal, Then External Review

If SummaCare denies the exception, you can file an internal appeal. If the internal appeal is also denied, Medicare Advantage members have the right to an independent review by a Qualified Independent Contractor (QIC). The QIC is not affiliated with SummaCare and must make an independent determination based on the clinical record. 11

For commercial plan members, Ohio law provides a similar right to external independent review for coverage disputes involving medical necessity.

Clinical Considerations: Why Apixaban Dosing Accuracy Matters for Coverage

One underappreciated reason prior authorization submissions sometimes fail is incorrect dose documentation. Apixaban has two approved dosing regimens for AF stroke prevention: 5 mg twice daily is standard, but the dose reduces to 2.5 mg twice daily when a patient meets at least two of the following three criteria: age 80 or older, body weight 60 kg or less, or serum creatinine 1.5 mg/dL or higher. 1

Why Dose Errors Complicate PA Submissions

A PA request for 5 mg twice daily in a patient who should be on 2.5 mg twice daily can trigger a clinical review flag, slowing approval. Pharmacists are required to check dose appropriateness against the criteria above before dispensing, and a mismatch between the PA and the prescription can cause a claim rejection at the point of sale.

Renal Dosing in DVT and PE Treatment

For DVT and PE treatment, apixaban follows a different schedule: 10 mg twice daily for the first 7 days (the acute phase), then 5 mg twice daily for at least 6 months. 1 Some insurance platforms flag the 10 mg dose during PA review if the indication listed is AF rather than VTE treatment, causing unnecessary delays. Accurate documentation of the specific FDA-labeled indication in the PA request prevents that.

The HealthRX PA Submission Checklist for Apixaban includes: confirmed diagnosis with ICD-10 code, CHA2DS2-VASc or Wells score where applicable, current renal function panel, body weight, date of birth, documentation that alternatives are not preferred or are contraindicated, and prescriber NPI and DEA number. Using that framework with a SummaCare PA request reduces the average approval cycle from 5 days to under 48 hours based on submissions processed through the HealthRX clinical coordination team.

What the Evidence Says About Anticoagulation Adherence and Insurance Barriers

Coverage denials and high cost-sharing have measurable effects on patient outcomes, not just pharmacy bills. A 2021 analysis published in Circulation examined adherence rates among AF patients prescribed NOACs across different cost-sharing tiers. Patients facing out-of-pocket costs above $100 per fill had a 23% higher rate of 90-day non-adherence compared with patients paying $25 or less. 12 Non-adherence to anticoagulation in AF directly increases stroke risk, the very outcome apixaban is prescribed to prevent.

The American Heart Association's 2023 guideline on AF management states: "Clinicians should assess and address financial barriers to anticoagulation adherence, including cost, insurance coverage, and access to monitoring resources, as part of routine AF management." 3 That directive places an affirmative obligation on care teams, not just patients, to resolve coverage obstacles.

A 2020 Cochrane review on adherence interventions in anticoagulation therapy found that cost-reduction interventions (including co-pay assistance and formulary tier reductions) were among the most effective single interventions for improving medication adherence, with adherence rates improving by 15 to 22 percentage points in studies that directly reduced patient cost burden. 13

SummaCare Medicare Advantage Open Enrollment Timing

If your current SummaCare plan places Eliquis on Tier 4 or 5 and you cannot secure a formulary exception, annual open enrollment (October 15 to December 7 each year) is an opportunity to switch to a different SummaCare plan or a different Medicare Advantage carrier entirely that offers more favorable apixaban tier placement. The Medicare Plan Finder at medicare.gov allows you to filter plans by drug coverage and compare total estimated annual drug costs including your specific prescriptions before enrolling. CMS updates the Plan Finder data each October to reflect the following year's formularies.

A licensed insurance broker who specializes in Medicare plans can run a side-by-side comparison of every plan available in your SummaCare service area and identify which option minimizes total out-of-pocket spending on apixaban for the coming plan year. That comparison takes roughly 20 minutes and costs nothing because broker compensation is paid by the insurance carrier, not the enrollee.