Does Security Health Plan Cover Eliquis?

Understanding Security Health Plan Drug Coverage

Security Health Plan, a Wisconsin-based health insurer affiliated with Marshfield Clinic Health System, offers commercial, Medicare Advantage, and ACA Marketplace plans across central and northern Wisconsin. Each plan type uses a tiered formulary that categorizes prescription drugs by cost-sharing level.

Eliquis is a brand-name medication with no generic equivalent currently on the market, which means it will not appear on the lowest-cost generic tiers. On most Security Health Plan formularies, brand-name anticoagulants like Eliquis sit on Tier 3 or Tier 4. The exact tier placement can shift during annual formulary reviews. Patients should verify their specific plan's drug list by calling the member services number on their insurance card or checking the online formulary tool at securityhealthplan.org.

For context on why tier placement matters: a 2023 analysis published in the Journal of Managed Care & Specialty Pharmacy found that moving a DOAC from Tier 3 to Tier 4 increased patient abandonment rates by 18.7%, meaning patients simply never filled their prescriptions [1]. This is not a minor administrative detail. Tier placement directly affects whether patients take a medication their physician has determined they need.

What Eliquis Costs on Security Health Plan

The monthly cost of Eliquis under Security Health Plan depends on three variables: your plan tier, whether you have met your deductible, and whether the drug requires prior authorization on your specific plan.

A standard 30-day supply of Eliquis 5 mg twice daily carries a retail price of approximately $600 to $650 without insurance. With Security Health Plan coverage at a Tier 3 level, commercially insured members typically pay a copay between $35 and $60 per month after meeting their deductible. Tier 4 placement pushes that copay to $70 to $90 or sometimes a coinsurance percentage (often 25% to 40% of the drug cost after negotiated discounts).

Medicare Advantage members on Security Health Plan face a different cost structure. During the initial coverage phase, copays for Tier 3 brand drugs commonly range from $42 to $47. Once a member enters the coverage gap (the "donut hole"), they pay 25% of the plan's negotiated price for brand-name drugs under the Medicare Part D benefit design, per CMS guidelines. For a drug priced like Eliquis, that 25% coinsurance during the gap phase could mean $150 or more per month.

The Bristol-Myers Squibb/Pfizer Eliquis copay card can reduce costs to as little as $10 per month for commercially insured patients. This card is not available to Medicare, Medicaid, or other government-insured patients due to federal anti-kickback regulations.

Why Eliquis Is Prescribed and Why Coverage Matters

Eliquis received FDA approval for multiple indications. The primary use is reducing stroke and systemic embolism risk in patients with non-valvular atrial fibrillation (AF). It is also approved for treating deep vein thrombosis (DVT) and pulmonary embolism (PE), preventing recurrent DVT/PE, and preventing venous thromboembolism after hip or knee replacement surgery.

The ARISTOTLE trial (N=18,201) demonstrated that apixaban 5 mg twice daily reduced stroke or systemic embolism by 21% compared to warfarin (HR 0.79 to 95% CI 0.66-0.95, P=0.01) while also reducing major bleeding by 31% (HR 0.69, P<0.001) and all-cause mortality by 11% (HR 0.89, P=0.047) [2]. These results established Eliquis as a first-line anticoagulant for AF.

The 2023 ACC/AHA/ACCP/HRS Guideline for Diagnosis and Management of Atrial Fibrillation gives DOACs (including apixaban) a Class I recommendation over warfarin for eligible patients with AF, stating: "In patients with AF who are appropriate for oral anticoagulation therapy, a DOAC is recommended over warfarin" [3]. This recommendation is relevant to coverage because it means any step therapy requirement to try warfarin first runs counter to current clinical guidelines.

Dr. John Mandrola, a cardiac electrophysiologist and writer for Medscape, has noted: "The evidence favoring DOACs over warfarin is consistent and strong. Asking patients to fail warfarin before accessing apixaban is a cost-driven decision, not an evidence-based one." This perspective reflects growing clinician frustration with formulary barriers to guideline-recommended therapies.

Prior Authorization and Step Therapy Requirements

Some Security Health Plan options require prior authorization (PA) before covering Eliquis. PA is most commonly triggered when the drug is prescribed for indications beyond non-valvular atrial fibrillation, such as extended VTE prophylaxis or off-label uses.

The PA process typically requires the prescribing physician to submit clinical documentation showing the patient meets FDA-approved labeling criteria. For AF patients, this includes confirmation of a CHA₂DS₂-VASc score of 2 or higher in men, or 3 or higher in women, along with documentation that the AF is non-valvular. Turnaround time for PA decisions at Security Health Plan is generally 24 to 72 hours for standard requests, though urgent requests can be processed in 24 hours.

Step therapy is a separate barrier. Certain Security Health Plan formularies may require documentation that the patient tried warfarin (or another older anticoagulant) before approving Eliquis. If your physician believes step therapy is clinically inappropriate, they can submit a step therapy exception request citing the ACC/AHA guidelines. A 2022 study in Circulation: Cardiovascular Quality and Outcomes found that step therapy requirements for DOACs were associated with a 21-day median delay in starting anticoagulation therapy [4]. For patients at high stroke risk, that delay carries real clinical consequences.

If Eliquis is denied outright, the appeals process follows Wisconsin insurance regulations. The first level is an internal appeal to Security Health Plan, which must be decided within 30 days for non-urgent cases. If the internal appeal is denied, patients can request an external review through the Wisconsin Office of the Commissioner of Insurance.

How Security Health Plan Compares to Other Wisconsin Insurers

Coverage of Eliquis varies across Wisconsin health plans, but most major insurers include it on their formularies at a brand-name tier.

Quartz Health Solutions, another prominent Wisconsin insurer, places Eliquis on Tier 3 with a typical copay of $40 to $50 for commercial plans. Group Health Cooperative of South Central Wisconsin similarly covers Eliquis at a brand-name tier. Dean Health Plan (now part of Quartz) historically covered Eliquis with fewer PA restrictions than some Security Health Plan options.

The variation is not unique to Wisconsin. A 2021 analysis in Health Affairs examined formulary placement of DOACs across 208 commercial plans and found that 73% placed apixaban on Tier 3 to 19% on Tier 4, and 8% required PA regardless of tier [5]. The authors noted that formulary restrictions on DOACs were inversely correlated with guideline adherence rates for anticoagulation in AF.

For Security Health Plan members specifically, the Medicare Advantage plans tend to have more predictable DOAC coverage because CMS requires Part D plans to cover "all or substantially all" drugs in certain protected classes. Anticoagulants are not a protected class under Part D, but CMS formulary review processes still provide some constraints on how restrictive coverage can be.

Strategies to Lower Your Eliquis Cost

Several approaches can reduce what you pay for Eliquis under Security Health Plan.

Manufacturer copay assistance. The Eliquis copay card program is available to commercially insured patients and can bring costs down to $10 per month. The program has annual caps (typically $6,400 per year in savings), but most patients will not reach that threshold.

Mail-order pharmacy. Security Health Plan's mail-order pharmacy benefit often provides a 90-day supply for the cost of two monthly copays. If your copay is $50 per month, a 90-day mail-order fill would cost $100 instead of $150. This represents a 33% savings.

Formulary exception requests. If Eliquis is on a higher tier (Tier 4) on your specific plan, your physician can submit a formulary tier exception request arguing that Eliquis should be covered at the lower Tier 3 copay. The physician must provide clinical rationale for why lower-tier alternatives (such as rivaroxaban/Xarelto) are not appropriate.

Patient assistance programs. For uninsured or underinsured patients, the Bristol-Myers Squibb Patient Assistance Foundation provides Eliquis at no cost to qualifying individuals. Income limits typically apply (generally at or below 300% of the federal poverty level).

Therapeutic alternatives. If cost remains a barrier, rivaroxaban (Xarelto) or edoxaban (Savaysa) may have different tier placement on your Security Health Plan formulary. A conversation with your prescriber about clinically appropriate alternatives could reduce your copay. The ENGAGE AF-TIMI 48 trial (N=21,105) demonstrated that edoxaban 60 mg daily was noninferior to warfarin for stroke prevention in AF (HR 0.79 to 97.5% CI 0.63-0.99, P<0.001 for noninferiority) with significantly lower rates of major bleeding [6].

What Happens When Eliquis Goes Generic

The patent situation around apixaban is complex. Bristol-Myers Squibb and Pfizer hold multiple patents on Eliquis, with key formulation patents extending to 2031 in some cases. Settlement agreements with several generic manufacturers may permit limited generic entry before full patent expiration.

When a generic apixaban does reach the market, it will almost certainly move to Tier 1 or Tier 2 on Security Health Plan's formulary, which would reduce copays to $5 to $20 per month for most plans. The FDA's Orange Book lists current patent and exclusivity information for apixaban.

Until then, a 2024 JAMA Internal Medicine analysis estimated that U.S. patients and insurers collectively pay $10 billion annually for apixaban, making it the single highest-revenue prescription drug in the United States [7]. This spending pressure is one reason insurers like Security Health Plan implement tiered copays and PA requirements.

Special Considerations for Medicare Advantage Members

Security Health Plan's Medicare Advantage plans (branded as "Security Health Plan Medicare Advantage") follow Part D drug coverage rules with some plan-specific additions. The Inflation Reduction Act of 2022 capped annual out-of-pocket Part D spending at $2,000 starting in 2025, which significantly benefits patients taking high-cost medications like Eliquis [8].

Under this cap, once a Medicare Advantage member's true out-of-pocket spending (copays, coinsurance, and deductible payments) reaches $2 to 000 in a calendar year, they pay nothing further for covered Part D drugs for the remainder of the year. For a patient paying $47 per month for Eliquis, that $2,000 cap would be reached in approximately 42 months if Eliquis were their only medication. But patients taking multiple brand-name drugs could reach the cap within a few months.

Medicare Advantage members should also check whether their plan offers a $0 deductible for Part D drugs. Some Security Health Plan Medicare Advantage options waive the Part D deductible entirely, meaning coverage begins with the first fill.

The CMS Medicare Plan Finder allows Medicare-eligible patients to enter their specific medications and compare Security Health Plan options side by side with other available Medicare Advantage plans in their ZIP code.

When to Talk to Your Doctor About Coverage Issues

Coverage barriers should not determine whether you take a medication your physician has prescribed to prevent stroke. A 2020 study in the Annals of Internal Medicine found that among AF patients prescribed a DOAC, 29.3% experienced primary nonadherence (never filling the initial prescription), and cost was the most frequently cited reason [9].

If you receive a denial letter from Security Health Plan for Eliquis, bring it to your next appointment. Your prescriber's office likely has staff dedicated to handling insurance appeals and PA submissions. The clinical evidence supporting DOACs over warfarin is strong enough that most appeals succeed when supported by current guideline citations.

For patients with a CHA₂DS₂-VASc score of 2 or above, the annual stroke risk without anticoagulation ranges from 2.2% to 15.2% depending on score, according to data from the original CHA₂DS₂-VASc validation study [10]. Each month without anticoagulation while waiting for coverage issues to resolve is a month of unprotected stroke risk.