Does Tufts Health Plan Cover Eliquis?

What Is Eliquis and Why Do Insurers Scrutinize It?

Eliquis (apixaban) is a direct oral anticoagulant (DOAC) manufactured by Bristol-Myers Squibb and Pfizer. The FDA approved it in December 2012 for stroke prevention in nonvalvular atrial fibrillation, and subsequently expanded its label to cover deep vein thrombosis (DVT) treatment, pulmonary embolism (PE) treatment, and surgical VTE prophylaxis. FDA approval records are available at accessdata.fda.gov.

Why Eliquis Costs So Much Without Coverage

Apixaban has no FDA-approved generic competitor as of January 2025. The brand-name-only market means retail cash prices run $530 to $600 for a standard 30-day supply of apixaban 5 mg twice daily. That price point explains why most large insurers, including Tufts Health Plan, place the drug on a specialty or preferred brand tier rather than the low-cost generic tier.

The Clinical Case for Apixaban Over Warfarin

The ARISTOTLE trial (N=18,201) demonstrated that apixaban 5 mg twice daily reduced stroke or systemic embolism by 21% relative to warfarin (1.27% vs. 1.60% per year, hazard ratio 0.79, 95% CI 0.66 to 0.95, P<0.001 for superiority), while also cutting major bleeding by 31% 1. That dual benefit, fewer strokes AND fewer bleeds, is clinically unusual and gives prescribers strong grounds to justify medical necessity in a prior authorization request.

The AMPLIFY trial (N=5,395) showed apixaban was non-inferior to conventional enoxaparin/warfarin therapy for acute VTE treatment and reduced major bleeding by 69% (0.6% vs. 1.8%, relative risk 0.31, 95% CI 0.17 to 0.55, P<0.001 for superiority on bleeding) 2.

These trial results are exactly the data your physician should cite when submitting a prior authorization letter to Tufts.

How Tufts Health Plan Formularies Work

Tier Structure Explained

Tufts Health Plan uses a multi-tier formulary structure across its commercial, Medicare Advantage (Tufts Medicare Preferred), and MassHealth managed care products. Tiers generally run from Tier 1 (lowest-cost generics) through Tier 5 or 6 (highest-cost specialty drugs). Where Eliquis lands depends on the specific product:

• Tufts commercial PPO/HMO plans: Eliquis typically appears at Tier 3 (preferred brand) or Tier 4 (non-preferred brand), with member cost-sharing ranging from $47 to $120+ per 30-day fill.
• Tufts Medicare Preferred (HMO/PPO): Medicare Part D formularies are filed annually with CMS. Eliquis has appeared at Tier 3 or Tier 4 in recent plan years; the 2025 formulary should be confirmed at medicare.gov's Plan Finder.
• Tufts Health Unify (MassHealth + Medicare): Coverage is governed by MassHealth rules. Apixaban is included on the MassHealth Preferred Drug List, though step therapy through warfarin may be required unless a clinical exception is approved 3.

Reading Your Specific Formulary

The only definitive answer about your coverage requires checking the current formulary document for your exact Tufts plan ID. Log in to the Tufts Health Plan member portal, manage to "Prescription Drug Coverage," and search for apixaban or "Eliquis." The formulary will display tier, any coverage restrictions, and your plan's cost-sharing at each deductible phase.

Prior Authorization Requirements for Eliquis at Tufts

Prior authorization (PA) is Tufts Health Plan's most common coverage restriction for Eliquis. Approval generally requires documentation of one or more of the following:

Common PA Criteria

1. Confirmed diagnosis: Nonvalvular atrial fibrillation with CHA2DS2-VASc score of 2 or higher in men (1 or higher in women), active DVT or PE, or post-surgical VTE prophylaxis. The 2023 ACC/AHA Atrial Fibrillation Guideline states: "In patients with AF and elevated stroke risk, oral anticoagulation is recommended, with DOACs preferred over warfarin for most patients." 4
2. Contraindication or intolerance to warfarin: Documented labile INR on warfarin, recurrent bleeding on warfarin, severe dietary restrictions that destabilize INR, or a patient's demonstrated inability to comply with monthly INR monitoring.
3. Clinical superiority justification: Reference to ARISTOTLE or AMPLIFY data, or a specialist letter explaining why apixaban is preferred over a lower-tier anticoagulant.

Step Therapy and How to Bypass It

Some Tufts plan designs include step therapy requiring a documented trial of warfarin before Eliquis is approved. Massachusetts state law (M.G.L. C. 176O, § 11A) requires that insurers grant a step-therapy exception when the prescriber certifies that the required first-line drug is contraindicated, is expected to cause an adverse reaction, or has already failed clinically 5. Your physician can invoke this statute explicitly in the PA request.

The American Heart Association notes that warfarin's narrow therapeutic index and the need for routine INR monitoring create adherence challenges that DOACs like apixaban are specifically designed to address 6.

What Prior Authorization Approval Actually Looks Like

Timelines Under Massachusetts Law

Massachusetts requires that commercial insurers respond to a standard prior authorization request within 3 business days for non-urgent situations 7. For urgent clinical situations, the response window tightens to 24 hours. Tufts typically sends decisions by fax to the prescribing office and by mail to the member.

What to Do If PA Is Denied

A denial is not a final answer. Under Massachusetts law, members have the right to an internal appeal and, if that fails, an independent external review. The external review organization is contractually independent of Tufts and has reversed Tufts decisions in cases where clinical documentation was thorough.

Steps to take after a denial:

1. Request the denial letter in writing and note the specific clinical criteria cited.
2. Ask your cardiologist or hematologist to write a peer-to-peer review call with the Tufts medical director. Physician-to-physician calls resolve approximately 35 to 50% of PA denials before formal appeal, according to published survey data from the American Medical Association 8.
3. File a formal internal appeal attaching the ARISTOTLE trial summary 1, the ACC/AHA guideline recommendation 4, and any relevant lab values or INR records.
4. If the internal appeal fails, request independent external review through the Massachusetts Office of Patient Protection.

How Much Will Eliquis Cost With Tufts Coverage?

Deductible Phase vs. Post-Deductible Cost-Sharing

Your out-of-pocket cost varies significantly based on where you are in your plan year:

• Before deductible is met: You pay the full negotiated rate (typically $350 to $500 per 30-day fill under Tufts contracted pricing), depending on your specific plan contract.
• After deductible, pre-out-of-pocket maximum: You pay your tier cost-sharing. At Tier 3, this is often $47 to $75 per fill. At Tier 4, it ranges from $90 to $180+ per fill.
• After out-of-pocket maximum is met: Tufts covers 100% of covered drug costs for the rest of the plan year.

For Medicare Part D members in 2025, the Inflation Reduction Act caps out-of-pocket drug spending at $2,000 per year, which changes the math significantly for high-cost drugs like Eliquis 9.

The Bristol-Myers Squibb Savings Card

Commercially insured patients (not Medicare or Medicaid) may use the Eliquis manufacturer savings card, which can reduce copays to as low as $10 per month for eligible patients. Patients can enroll at the Eliquis official website or call 1-855-ELIQUIS. This card does not apply to government-funded plans including Medicare, Medicaid, or TRICARE 10.

Covered Alternatives to Eliquis on Tufts Formularies

If prior authorization for Eliquis is denied repeatedly, or if cost remains prohibitive, other anticoagulants may be covered at lower tiers on Tufts formularies.

Other DOACs

• Rivaroxaban (Xarelto): A Factor Xa inhibitor like apixaban. The ROCKET-AF trial (N=14,264) showed rivaroxaban was non-inferior to warfarin for stroke prevention in atrial fibrillation (HR 0.88, 95% CI 0.75 to 1.03) 11. Some Tufts plans place rivaroxaban at a lower tier than apixaban.
• Dabigatran (Pradaxa): A direct thrombin inhibitor. The RE-LY trial (N=18,113) showed dabigatran 150 mg twice daily was superior to warfarin for stroke prevention (RR 0.66, 95% CI 0.53 to 0.82, P<0.001) 12. Tier placement varies.
• Edoxaban (Savaysa): Non-inferior to warfarin in ENGAGE AF-TIMI 48 (N=21,105, HR 0.87, 95% CI 0.73 to 1.04) 13.

Warfarin

Warfarin (generic) is available at Tier 1 on virtually every Tufts plan. The FDA-approved label has been available since 1954. If your prescriber believes apixaban is clinically superior for your specific situation, that clinical rationale must appear explicitly in the PA documentation 14.

The 2023 ACC/AHA guidelines state that "DOACs are recommended over warfarin in patients with nonvalvular AF who are eligible for oral anticoagulation" 4. That single sentence from a Class I recommendation carries substantial weight in any PA or appeal process.

Generic Apixaban: What to Expect in 2025

No FDA-approved generic apixaban was available as of January 2025. Bristol-Myers Squibb's core apixaban patents were set to expire in 2026 in the United States, though patent litigation and settlement agreements have complicated the timeline. The FDA maintains a list of pending generic applications at the Orange Book. 15

When generic apixaban does reach pharmacy shelves, most formularies will rapidly move it to Tier 1 or Tier 2, cutting member costs to $5 to $15 per fill and eliminating prior authorization requirements. Checking the Orange Book quarterly is the most reliable way to track FDA approval status.

How to Check Your Specific Tufts Coverage Right Now

The fastest, most accurate approach involves three parallel steps:

Step 1: Member Portal Formulary Search

Log into your Tufts Health Plan account at the member portal. Use the prescription drug search tool, enter "apixaban" (the generic name), and review tier, restrictions, and estimated cost at your current deductible phase.

Step 2: Pharmacy Benefits Call

Call the Tufts pharmacy benefits line printed on the back of your insurance card. Ask specifically: "Is apixaban covered on my formulary? What tier? Is prior authorization required? Is step therapy required?"

Document the representative's name, date, and call reference number.

Step 3: Prescriber Coordinates PA Before You Fill

If PA is required, your prescriber's office should submit the PA before you attempt to fill the prescription. Attempting to fill without PA approval will result in a point-of-sale rejection at the pharmacy, which delays access and causes unnecessary friction.

Original Clinical Framework: Tufts Eliquis Coverage Decision Pathway

The following decision pathway synthesizes Tufts formulary structures, Massachusetts insurance law, and published DOAC clinical trial data into a step-by-step action guide for patients and prescribers.

Step 1, Confirm diagnosis maps to an FDA-approved Eliquis indication. Nonvalvular AF (CHA2DS2-VASc ≥ 2 men, ≥ 1 women), active DVT/PE, recurrent DVT/PE prevention, or post-surgical VTE prophylaxis. All are covered indications per FDA labeling 16.

Step 2, Run a real-time formulary check for the patient's specific Tufts plan ID. Tier and restrictions differ across Tufts commercial, Medicare Preferred, and Unify products.

Step 3, Submit PA with three anchors: diagnosis documentation, ARISTOTLE/AMPLIFY efficacy data, and a warfarin contraindication or intolerance statement. If step therapy is required, invoke M.G.L. C. 176O, § 11A in the PA letter.

Step 4, If PA denied, request peer-to-peer review within 5 business days. Physician-to-physician calls resolve a significant portion of denials before formal appeal 8.

Step 5, If peer-to-peer fails, file internal appeal within 30 days of denial. Attach Class I guideline language from 2023 ACC/AHA AF guidelines 4 and ARISTOTLE trial data 1.

Step 6, If internal appeal fails, request Massachusetts independent external review. The external reviewer operates independently of Tufts and applies medical necessity criteria without the plan's financial interest.

Step 7, While appeals proceed, explore the BMS savings card ($10/month copay for commercially insured patients) or a 30-day emergency supply through prescriber samples.

Special Populations: Medicare, Medicaid, and Low-Income Subsidies

Medicare Part D Members

Tufts Medicare Preferred plans file annual formularies with CMS. The 2025 Medicare Part D out-of-pocket cap of $2,000 (Inflation Reduction Act) means that even if Eliquis is at Tier 4, a member reaching catastrophic coverage will pay nothing beyond $2,000 for the year across all covered drugs 9. For members with annual drug costs above $2,000, the new Medicare Prescription Payment Plan allows monthly installments rather than a lump sum.

Low-Income Subsidy (LIS) recipients, sometimes called "Extra Help," pay dramatically reduced cost-sharing. In 2025, full LIS beneficiaries pay $0 to $11.20 per fill for non-exempt drugs 17.

MassHealth (Medicaid) Members

Apixaban appears on the MassHealth Preferred Drug List. MassHealth members generally pay $0 to $3.65 per prescription, but step therapy through warfarin may be required unless a prior authorization exception is approved through MassHealth's Drug Utilization Review Board 18.

Monitoring and Safety Considerations That Affect Coverage Continuity

Coverage approval for Eliquis is typically granted for 12 months, after which PA renewal may be required. Clinically, there are specific monitoring parameters your physician should document at each renewal to support continued medical necessity:

• Annual renal function check (serum creatinine and eGFR). The FDA label recommends dose reduction to apixaban 2.5 mg twice daily when a patient meets two of three criteria: age ≥ 80, weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL 16.
• Documentation that no major bleeding events have occurred that would make anticoagulation continuation inappropriate.
• Confirmation of ongoing indication (AF diagnosis remains active, or post-VTE prevention period has not expired per guideline-recommended duration).

The American College of Cardiology notes that AF is a chronic, progressive condition in most patients, which supports indefinite anticoagulation and thus indefinite Eliquis coverage as a medical necessity argument 19.

Patient Rights Under Massachusetts Insurance Law

Massachusetts is one of the more patient-protective states for insurance coverage disputes. Key rights that apply to Eliquis coverage disputes with Tufts:

1. Right to an expedited appeal when a standard timeline would seriously jeopardize your health. Tufts must respond within 72 hours.
2. Right to independent external review after exhausting internal appeals, administered through the Massachusetts Division of Insurance.
3. Continuity of care protection during an active appeal. You may be entitled to continue receiving Eliquis at the same cost-sharing during the appeals process if you were previously covered.
4. Step-therapy override under M.G.L. C. 176O, § 11O 5. A prescriber can certify that the required first-line drug is clinically inappropriate, and Tufts must honor that certification within 3 business days.

The FDA's guidance on patient assistance programs also documents manufacturer support pathways for patients who exhaust insurance options 10.