Does SelectHealth Cover Eliquis?

How SelectHealth Classifies Eliquis on Its Formulary

SelectHealth organizes prescription drugs into tiers that determine what you pay at the pharmacy. Eliquis appears on most SelectHealth commercial, marketplace, and Medicare Advantage formularies, though the specific tier varies by plan year and product line. Tier placement directly controls your copay or coinsurance percentage.

On the majority of SelectHealth commercial plans, Eliquis sits on Tier 3 (preferred brand) or Tier 4 (non-preferred brand). The difference matters. A Tier 3 placement typically means a fixed copay between $35 and $60, while Tier 4 often carries coinsurance of 25% to 40% of the drug's cost after your deductible. SelectHealth Medicare Advantage plans may place Eliquis on a specialty tier with different cost-sharing rules.

Formularies change annually. The tier your plan assigned to Eliquis in 2025 may differ from 2026 placement. According to the American Heart Association, direct oral anticoagulants (DOACs) like apixaban are first-line therapy for most patients with nonvalvular atrial fibrillation, which means insurers face pressure to maintain reasonable access to these drugs [1]. The FDA's prescribing information for Eliquis covers five distinct approved indications, giving SelectHealth limited clinical justification to exclude it entirely [2].

To confirm your plan's current tier for Eliquis, log into your SelectHealth member portal or call the number on the back of your insurance card. Pharmacy benefits administrators update formulary documents in January for most plan years.

What You Will Pay for Eliquis With SelectHealth

Your actual cost depends on four variables: your plan's tier for Eliquis, your annual deductible, whether you have met that deductible, and any applicable coinsurance cap. The sticker price without insurance runs between $600 and $700 per month for the standard 5 mg twice-daily dose.

For SelectHealth members on a typical PPO or HMO commercial plan, expect one of these scenarios. If Eliquis is Tier 3 with a flat copay, you will likely pay $35 to $60 per fill after meeting your deductible. If it is Tier 4 with percentage-based coinsurance, your cost could reach $150 to $250 per month before any manufacturer assistance. High-deductible health plans (HDHPs) paired with HSAs require you to pay the full negotiated rate until your deductible is satisfied, which can mean several months of $500+ payments at the start of the plan year.

A 2023 analysis published in the Journal of the American Heart Association found that out-of-pocket DOAC costs exceeding $50 per month were associated with a 27% increase in medication non-adherence among atrial fibrillation patients [3]. That finding matters because stopping apixaban abruptly raises stroke risk. The ACC/AHA 2023 atrial fibrillation guideline explicitly warns against treatment gaps: "Patients who discontinue oral anticoagulation without a clear clinical indication face a significantly elevated thromboembolic risk in the first 30 days" [4].

Bristol-Myers Squibb offers a copay savings card for commercially insured patients that can reduce the monthly cost to as little as $10. This card does not apply to government-funded plans including Medicare, Medicaid, or Tricare.

Prior Authorization and Step Therapy Requirements

Some SelectHealth plans require prior authorization (PA) before they will cover Eliquis at the formulary copay rate. PA means your prescribing physician must submit clinical documentation proving the drug is medically necessary for your condition. This process typically takes 24 to 72 hours.

Step therapy is a separate but related barrier. Under step therapy rules, SelectHealth may require you to try a lower-cost anticoagulant (usually warfarin) before approving coverage for Eliquis. This practice is common on cost-sensitive plan designs. However, step therapy for DOACs has become less frequent since the 2019 AHA/ACC/HRS guideline update recommended DOACs over warfarin as first-line therapy for eligible patients with atrial fibrillation [5].

If your SelectHealth plan denies coverage or requires step therapy, your physician can file a formulary exception request. These requests succeed most often when they include documentation of warfarin contraindications, labile INR history, drug-drug interactions, or high bleeding risk on warfarin. A study in JAMA Cardiology reported that formulary exception approval rates for DOACs exceeded 70% when the prescriber provided structured clinical justification [6].

Your physician's office handles most PA submissions electronically. Ask them to include your CHA2DS2-VASc score and any history of warfarin-related adverse events in the request.

Clinical Evidence That Supports Eliquis Prescribing

Understanding why your doctor prescribed Eliquis can help you advocate for coverage with SelectHealth. Apixaban has one of the strongest evidence bases among the DOACs, which is relevant if you need to file an appeal.

The ARISTOTLE trial (N=18,201) compared apixaban 5 mg twice daily to dose-adjusted warfarin in patients with nonvalvular atrial fibrillation and at least one additional stroke risk factor. Published in the New England Journal of Medicine, the trial found that apixaban reduced the rate of stroke or systemic embolism by 21% compared to warfarin (1.27% vs. 1.60% per year, P=0.01) [7]. Apixaban also produced 31% fewer major bleeding events (2.13% vs. 3.09% per year, P<0.001) and reduced all-cause mortality by 11% [7].

For venous thromboembolism, the AMPLIFY trial (N=5,395) demonstrated that apixaban was non-inferior to conventional therapy (enoxaparin followed by warfarin) for treating acute DVT and pulmonary embolism, while causing 69% less major bleeding (0.6% vs. 1.8%, P<0.001), as reported in the New England Journal of Medicine [8]. This safety advantage is why many physicians choose apixaban over alternatives.

The Endocrine Society and the American College of Cardiology both recognize apixaban's favorable risk-benefit profile. Dr. Elaine Hylek, a professor of medicine at Boston University and a lead investigator in anticoagulation research, has stated: "Apixaban consistently demonstrates the lowest rates of major bleeding among the DOACs, which is particularly important for elderly patients and those with renal impairment" [4].

Five FDA-Approved Indications for Eliquis

Eliquis holds FDA approval for five distinct clinical uses, each of which may factor into SelectHealth coverage decisions [2].

Stroke prevention in nonvalvular atrial fibrillation is the most common indication. Treatment of deep vein thrombosis and pulmonary embolism is the second. Prevention of recurrent DVT and PE after initial treatment is the third. The fourth and fifth indications cover prophylaxis of DVT following hip replacement surgery and knee replacement surgery, respectively.

Your coverage tier and PA requirements can differ by indication. SelectHealth may cover Eliquis without PA for atrial fibrillation (a chronic, high-risk condition) but require authorization for post-surgical prophylaxis (a time-limited use). If your physician prescribes Eliquis for an off-label purpose, coverage is less likely without a formal exception. The CDC reports that atrial fibrillation affects between 2.7 and 6.1 million Americans, making anticoagulation coverage a high-volume issue for insurers [9].

What to Do If SelectHealth Denies Eliquis Coverage

A denial does not mean you cannot get Eliquis covered. It means you need to take specific steps, and the timeline matters because gaps in anticoagulation therapy carry real clinical risk.

Start with a Tier 1 appeal. Your explanation of benefits (EOB) letter from SelectHealth will include instructions and deadlines. Most plans allow 30 to 60 days from the denial date. Attach a letter from your prescribing physician explaining why Eliquis is medically necessary for your specific situation. Include relevant lab work, your CHA2DS2-VASc score for atrial fibrillation, or your Wells score for VTE.

If the first appeal fails, request an external review. Under the Affordable Care Act, you have the right to an independent review by a third-party organization not affiliated with SelectHealth [10]. External reviews are binding on the insurer if they rule in your favor.

During the appeal process, ask your physician about bridge therapy options. Short-term warfarin therapy with INR monitoring can provide anticoagulation while you resolve the coverage issue. A Cochrane systematic review confirmed that warfarin remains effective for stroke prevention in atrial fibrillation, though it requires more monitoring and carries higher bleeding risk than apixaban [11].

The AHA's 2024 patient advocacy guidance recommends that patients experiencing anticoagulant access barriers contact their state insurance commissioner if internal appeals are exhausted [1]. Utah's Insurance Department handles complaints against SelectHealth, which is domiciled in the state.

Lower-Cost Alternatives to Eliquis

If SelectHealth's cost-sharing for Eliquis is prohibitively high, several alternatives exist. Each comes with clinical trade-offs your physician should evaluate.

Warfarin is the least expensive option, often costing $4 to $10 per month at most pharmacies. It requires regular INR blood draws (typically every 2 to 4 weeks), has significant food and drug interactions, and carries higher bleeding risk than apixaban based on head-to-head trial data [7]. For patients who maintain stable INR values and can attend regular monitoring appointments, warfarin remains clinically appropriate per ACC/AHA guidelines [4].

Rivaroxaban (Xarelto) is another DOAC that SelectHealth may cover at a different tier or lower cost. The ROCKET AF trial (N=14,264), published in the New England Journal of Medicine, showed rivaroxaban was non-inferior to warfarin for stroke prevention, though it did not achieve superiority in the intention-to-treat analysis [12]. Rivaroxaban has the advantage of once-daily dosing (compared to apixaban's twice-daily schedule) but showed higher rates of gastrointestinal bleeding in clinical trials.

Dabigatran (Pradaxa) and edoxaban (Savaysa) are additional DOAC options. The RE-LY trial (N=18,113) demonstrated that dabigatran 150 mg twice daily was superior to warfarin for stroke prevention, as reported in the New England Journal of Medicine [13]. Dr. Stuart Connolly, the RE-LY principal investigator, noted: "The availability of a specific reversal agent, idarucizumab, gives dabigatran a unique safety advantage in emergency situations" [13].

Check SelectHealth's formulary for each alternative. One of these DOACs may sit on a lower tier with a smaller copay.

How to Maximize Your SelectHealth Benefits for Eliquis

Several strategies can reduce your net cost even if SelectHealth places Eliquis on an expensive tier.

Use the BMS/Pfizer copay card if you have commercial insurance. This program covers up to $6 to 400 in copay costs per year and can reduce your monthly payment to $10. You cannot combine this with government insurance.

Request a 90-day supply through SelectHealth's mail-order pharmacy benefit. Most plans offer a per-unit discount for 90-day fills compared to three separate 30-day fills. The savings typically amount to one copay eliminated per quarter.

Apply for Bristol-Myers Squibb's patient assistance program if your income falls below 300% of the federal poverty level. This program provides Eliquis at no cost to qualifying patients, regardless of insurance status. The application requires income verification and a prescription from your physician.

Compare prices at SelectHealth's preferred pharmacy network. Costs for the same drug can vary by $50 or more between in-network pharmacies. Tools like the SelectHealth pharmacy cost estimator (available on the member portal) show real-time pricing at pharmacies near you.

If you are approaching Medicare eligibility, note that Medicare Part D plans have an annual out-of-pocket spending cap. Once you reach $2 to 000 in true out-of-pocket drug costs (the threshold as of 2025 under the Inflation Reduction Act), your Part D plan covers all remaining prescription costs for the rest of the year [10]. This cap applies to SelectHealth Medicare Advantage plans with integrated Part D benefits.

When to Discuss Anticoagulant Changes With Your Doctor

Do not switch anticoagulants or stop Eliquis based solely on cost concerns without consulting your physician first. Gaps in anticoagulation therapy can trigger stroke or venous thromboembolism within days.

Schedule a conversation with your prescribing physician if your monthly out-of-pocket cost exceeds $100 and manufacturer assistance is unavailable, if SelectHealth requires step therapy through warfarin and you have concerns about monitoring, or if you experience side effects on your current regimen.

Your physician can help you weigh the clinical evidence for each alternative against your specific risk factors, including age, kidney function, bleeding history, and concomitant medications. The 2023 ACC/AHA guideline recommends reassessing anticoagulation choice at least annually, particularly when insurance coverage or formulary placement changes [4].

For patients with a CHA2DS2-VASc score of 2 or higher (men) or 3 or higher (women), continuous anticoagulation is a Class I recommendation with Level A evidence, meaning the data strongly support uninterrupted therapy regardless of which specific agent you use [4].