Does Quartz Health Solutions Cover Eliquis?

How Quartz Health Solutions Handles Eliquis on Its Formulary

Quartz Health Solutions, a regional insurer serving Wisconsin and parts of neighboring states, publishes a multi-tier formulary that categorizes drugs by cost-sharing level. Eliquis appears on most current Quartz formularies as a brand-name anticoagulant placed on Tier 3 (preferred brand) or Tier 4 (non-preferred brand), depending on the specific plan. That placement matters because it determines whether your copay is a flat dollar amount or a percentage-based coinsurance.

Quartz offers several product lines: Quartz-branded HMO and PPO plans sold on the ACA marketplace, employer-sponsored group plans, and Medicare Advantage options. Each product line may carry a different version of the formulary. A Quartz marketplace Silver plan, for example, might list Eliquis at a different cost-sharing level than a Quartz employer group plan. The only reliable way to confirm your specific tier placement is to search the drug formulary tool on the Quartz member portal or call the number on the back of your insurance card.

When a drug sits on Tier 3, members typically pay a copay between $40 and $75 per fill. Tier 4 placement usually means coinsurance of 25% to 50% of the negotiated drug cost, which could push a 30-day supply of Eliquis above $150 out of pocket before any manufacturer assistance. The American Heart Association notes that medication cost is one of the top barriers to anticoagulant adherence in atrial fibrillation patients, making formulary tier placement a clinically significant issue.

Why Eliquis Is Widely Covered but Rarely Cheap

Eliquis earned its place on most commercial formularies because of strong clinical trial evidence. The ARISTOTLE trial (N=18,201) demonstrated that apixaban 5 mg twice daily reduced stroke and systemic embolism by 21% compared to warfarin (HR 0.79, 95% CI 0.66 to 0.95) while also lowering major bleeding by 31% (HR 0.69, 95% CI 0.60 to 0.80) [1]. Those dual advantages over warfarin made Eliquis a first-line recommendation in the 2019 AHA/ACC/HRS focused update on atrial fibrillation management [2].

The challenge is price. Bristol Myers Squibb and Pfizer have maintained Eliquis at a wholesale acquisition cost exceeding $550 per month. No generic apixaban has reached the U.S. market as of mid-2026, although patent litigation settlements suggest generic entry could begin in the coming years. Until then, insurers like Quartz balance clinical evidence against budget impact by placing Eliquis on mid-to-upper formulary tiers rather than excluding it outright.

Rivaroxaban (Xarelto) went generic in late 2025, giving insurers a lower-cost DOAC alternative. Some Quartz plans have responded by implementing step therapy protocols that require a trial of generic rivaroxaban before approving Eliquis. This does not mean Eliquis is unavailable. It means your prescriber may need to document why apixaban is specifically necessary for you.

Prior Authorization and Step Therapy Requirements

Not every Quartz member will face prior authorization for Eliquis, but some will. Quartz has historically required prior authorization for DOACs when prescribed for indications beyond the most common FDA-approved uses. Stroke prevention in non-valvular atrial fibrillation is typically approved without extra paperwork. Treatment of acute deep vein thrombosis or pulmonary embolism also tends to process smoothly.

Step therapy is a separate gate. If your Quartz plan applies step therapy to Eliquis, your pharmacy claim will reject with a message indicating that a preferred alternative must be tried first. Your prescribing physician can submit a step therapy exception request, documenting clinical reasons why you need apixaban specifically. Valid reasons include a history of adverse reactions to rivaroxaban, renal dosing considerations (apixaban requires less dose adjustment in moderate renal impairment than some alternatives), or drug interactions that make other DOACs less safe for you.

The 2023 AHA scientific statement on DOAC use emphasizes that switching between anticoagulants solely for cost reasons should involve careful clinical assessment, particularly in patients who are stable on their current regimen [3]. Your cardiologist or primary care physician can cite this guidance in an appeal letter.

Turnaround time for Quartz prior authorization decisions is typically 24 to 72 hours for standard requests. Urgent requests, such as for a patient being discharged from the hospital after a PE, should receive a decision within 24 hours per ACA regulations.

What You Will Actually Pay Out of Pocket

Your cost depends on four variables: formulary tier, plan design (copay vs. coinsurance), deductible status, and whether you use a copay assistance card. Here is a realistic breakdown.

If your Quartz plan places Eliquis on Tier 3 with a $50 copay and your deductible is already met, you pay $50 per 30-day fill. That totals $600 per year. If Eliquis sits on Tier 4 at 30% coinsurance and the plan's negotiated price is $500, your cost per fill is $150, or $1,800 per year, before hitting your out-of-pocket maximum.

Bristol Myers Squibb offers the Eliquis 360 Support program, which includes a copay card for commercially insured patients. Eligible members pay as little as $10 per month, with the card covering up to a set annual maximum. This card cannot be used with government insurance (Medicare, Medicaid, Tricare). For Quartz commercial plan members, combining your insurance benefit with the copay card can reduce your annual cost to $120.

Patients with Quartz Medicare Advantage plans face different math. Under Medicare Part D, Eliquis falls into the brand-name drug tier. After the Inflation Reduction Act's $2,000 annual out-of-pocket cap took effect for Part D in 2025, Medicare beneficiaries spending more than $2,000 on all covered drugs combined pay nothing further for the remainder of the plan year [4]. The Centers for Medicare & Medicaid Services confirmed this cap applies to all Part D-covered drugs, including Eliquis.

How Eliquis Compares to Alternatives Quartz May Prefer

Quartz, like most insurers, weighs clinical equivalence against cost. Here is how Eliquis stacks up against the anticoagulants Quartz might push you toward.

Generic rivaroxaban (Xarelto). Once-daily dosing is convenient. The ROCKET AF trial (N=14,264) showed rivaroxaban was non-inferior to warfarin for stroke prevention in AF (HR 0.79, 95% CI 0.66 to 0.96 in on-treatment analysis) [5]. The bleeding profile differs from apixaban: rivaroxaban carries higher rates of gastrointestinal bleeding. A 2022 meta-analysis in The Lancet confirmed that apixaban had the most favorable GI bleeding profile among DOACs [6]. If your Quartz plan prefers generic rivaroxaban but you have a history of GI bleeding, your prescriber has strong evidence to request an exception.

Warfarin. Pennies per day. It requires INR monitoring every 2 to 4 weeks, has extensive food and drug interactions, and carries higher intracranial hemorrhage risk than all DOACs. The ACC/AHA guidelines recommend DOACs over warfarin for most patients with non-valvular AF [2]. Quartz rarely mandates warfarin as a first step anymore, but a few legacy plan designs still include it in step therapy.

Edoxaban (Savaysa). Less commonly prescribed, and the ENGAGE AF-TIMI 48 trial (N=21,105) showed non-inferiority to warfarin [7]. Edoxaban has a unique limitation: the FDA label warns against use in patients with CrCl >95 mL/min due to reduced efficacy in that population [8]. Quartz does not typically prefer edoxaban over apixaban.

Dabigatran (Pradaxa). The RE-LY trial (N=18,113) showed the 150 mg dose was superior to warfarin for stroke prevention but carried higher GI bleeding [9]. Dabigatran requires twice-daily dosing, must be stored in original packaging, and has the only DOAC-specific reversal agent (idarucizumab). Some Quartz formularies list generic dabigatran at a lower tier than Eliquis.

Tips for Getting Eliquis Approved and Affordable on Quartz

Start at the pharmacy counter. If your first claim rejects, ask the pharmacist for the specific rejection code. "Prior authorization required" and "step therapy required" are different problems with different solutions.

For prior authorization, your doctor's office submits a coverage determination request to Quartz. Include the diagnosis code, relevant clinical history (CHA₂DS₂-VASc score for AF patients, details of the thrombotic event for VTE patients), and a brief statement explaining why apixaban is the appropriate choice. Reference the ARISTOTLE trial's bleeding advantage if applicable.

For step therapy exceptions, document any prior trial of the preferred alternative, intolerance, contraindication, or clinical evidence supporting apixaban as the better option for your specific situation. A 2021 study in the Annals of Internal Medicine found that patients switched between DOACs for non-clinical reasons had higher rates of medication discontinuation [10]. This supports keeping patients on the DOAC they started with.

If you are denied, Quartz members have the right to appeal. The internal appeal must be reviewed by a physician who did not make the original denial. External review through the Wisconsin Office of the Commissioner of Insurance is available if the internal appeal fails.

Apply for the Eliquis copay card at the manufacturer's support website. Enrollment takes about five minutes and requires your insurance information. The card applies automatically at participating pharmacies once activated.

Consider mail-order pharmacy. Quartz partners with mail-order services that may offer 90-day supplies at reduced copays. A 90-day fill through mail order often costs the equivalent of two monthly copays instead of three.

When Quartz Might Not Cover Eliquis at All

Complete exclusion is rare but possible. Quartz plans with extremely restrictive formularies, sometimes seen in the most cost-sensitive employer group designs, could exclude all brand-name DOACs in favor of generic alternatives. If Eliquis is excluded entirely from your formulary, your options include a formulary exception request (your doctor argues medical necessity), switching to a covered alternative, paying cash with a discount card (GoodRx and similar platforms sometimes offer Eliquis for $430 to $500 per month, though this does not count toward your insurance deductible or out-of-pocket maximum), or considering a plan change during open enrollment.

"Most formulary exclusions of brand-name DOACs reflect cost management rather than clinical judgment," according to a 2023 review in the Journal of the American College of Cardiology examining insurance barriers to anticoagulation [3]. The review found that 94% of commercial health plans covered at least one DOAC without prior authorization.

If you are approaching open enrollment, check the Quartz formulary for the upcoming plan year before re-enrolling. Formularies change annually. A plan that covers Eliquis on Tier 3 this year might move it to Tier 4 or add step therapy next year.

Renal Dosing and Its Impact on Coverage

Eliquis dose reduction (2.5 mg twice daily instead of 5 mg twice daily) is indicated for patients who meet at least two of three criteria: age 80 or older, body weight 60 kg or less, or serum creatinine 1.5 mg/dL or higher [11]. The FDA prescribing information specifies these criteria precisely.

From a coverage standpoint, the reduced dose costs the same as the full dose per tablet. However, some prior authorization forms ask about renal function. Documenting CrCl and eGFR on the PA form helps Quartz reviewers verify appropriate dosing. Incorrect dosing is a common reason for PA denial or delay.

For patients on dialysis, current evidence is limited. The KDIGO 2024 guidelines note that DOACs lack strong data in dialysis populations, though apixaban has more observational data than other DOACs in this group [12]. If your nephrologist prescribes Eliquis for dialysis-dependent AF, expect Quartz to require prior authorization with supporting documentation.

Understanding Your Quartz Formulary Document

Every Quartz member has access to their plan's formulary, either through the member portal or by requesting a printed copy. The formulary lists each covered drug with its tier, any restrictions (PA, ST, QL for quantity limits), and whether specialty pharmacy dispensing is required.

Search for "apixaban" or "Eliquis" in the formulary PDF. The entry will show a tier number and restriction codes. "PA" means prior authorization is required. "ST" means step therapy applies. "QL" means there is a quantity limit (typically 60 tablets per 30 days for Eliquis, matching the twice-daily dosing). No restriction code means the drug is covered at the listed tier without additional requirements.

If the formulary says "NF" (non-formulary), the drug is not on your plan's covered list. That does not make it impossible to obtain through Quartz, but it requires a formulary exception, and your out-of-pocket cost will be at the highest tier or potentially uncovered entirely.

Compare your formulary annually during open enrollment. The Kaiser Family Foundation's 2024 employer health benefits survey found that 30% of employer-sponsored plans changed at least one cardiovascular drug's tier placement year over year [13]. Staying informed prevents surprise costs at the pharmacy.