Final Tip: Its Helpful To Understand The Medicare Part D Payment Stages
The donut hole can seem overwhelming, but its just one of four payment stages with Medicare Part D. The payment stage youre in determines the amount you pay when you fill a prescription. You always begin each year in the deductible stage or the initial coverage stage, depending on your plan. A final helpful tip is to learn about each of the Part D payment stages and understand how your financial responsibilities will change in each.
What Is Eliquis Used To Treat
A healthcare provider may prescribe Eliquis for one of the following reasons:
- To reduce the risk of stroke due to non-valvular atrial fibrillation afib .
- To treat blood clots in the veins of the lungs or legs and prevent them from occurring again .
- To decrease the risk of deep vein thrombosis in patients who have undergone hip or knee replacement surgery.
What Does Medicare Part D Cost
Like Medicare Advantage plans, Part D stand-alone plans will also vary in costs based on the plan you choose. Each plan negotiates prices with drug manufactures and pharmacies. Your copays and coinsurance rates are based on these prices and on guidelines set by Medicare. You can find explanations of specific drug costs in each Part D plan’s Summary of Benefits or Evidence of Coverage materials.
Your total prescription drug costs will also be impacted by the number of prescriptions you take, how often you take them, if you get them from an in-network or out-of-network pharmacy, and what Part D coverage stage you are in. Your costs may also be less if you qualify for the Extra Help program.
First, let’s look at what kinds of costs you could pay for Part D, then dive into the different coverage stages and how they work.
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What Is The Best Medicare Part D Plan For Eliquis
Eliquis® is an expensive brand-name prescription that our clients ask us about quite often. When a Medicare enrollee is taking an expensive prescription like Eliquis it is important to select a Medicare Part D plan that covers the drug well.
Medicare Part D plans are government regulated and, for the most part, they are all structured the same. That said, they each unique in their competitiveness for different lists of prescriptions. We have found that the best way to compare Medicare Part D plans is to use a Medicare Part D cost comparison tool to verify which plans have the drug on formulary.
Eliquis seems to come up a lot for us because it is widely prescribed and it has a hefty price tag of over $450 for a 30-day supply. If you select a Medicare Part D plan that does not have the drug on formulary, then you could wind up paying full price. With the right Medicare Part D plan, the drug cost can be reduced to as low as $42/month.
We can’t offer a specific recommendation on a plan that is best for Eliquis and the reasons are numerous. For one, plan availability varies widely depending on location. Additionally, we would want to take all of your medications into account as well as your preferred pharmacy before making a recommendation.
The good news is that we are well-versed in helping with Medicare Part D plan selection. Please don’t hesitate to give us a call and we can make sense of your most competitive Medicare Part D options.
The Part D Standard Benefit
At a minimum, plan sponsors must offer a standard benefit package mandated by law. The standard benefit includes an annual deductible and a gap in coverage, previously referred to as the Donut Hole. Sponsors may also offer plans that differ from but are actuarially equivalent to the standard benefit. Finally, they may also offer enhanced plans that provide benefits in addition to the standard benefit. Typically, the enhanced plans offer some coverage during the Donut Hole.
The Standard Benefit is defined in terms of the financial structure of the cost-sharing, not the drugs that must be covered under the plan.
Medicare does not establish premium amounts for plans. Instead, premiums are established through an annual competitive bidding process and evaluated by CMS. Premiums vary from plan to plan and from region to region. Medicare does establish the maximum deductible amount, the Initial Coverage Limit, the TrOOP threshold, and Catastrophic Coverage levels every year. The table below shows the standard benefit for this year .
Standard Part D Benefit 2020-2021
Alternatives to the Standard Benefit
Income-Related Monthly Adjustment Amount Part D
Income-Related Adjustments 2021
|Greater than or equal to $500,000||Greater than or equal to $750,000||$77.10|
The Donut Hole
Once beneficiaries reach their out-of-pocket threshold costs), they move out of the Donut Hole and into Catastrophic Coverage.
The Donut Hole Discount
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Medicare Coverage Of Eliquis
If you have Medicare and need an Eliquis prescription, there are a few options available to you. Original Medicare doesnt cover self-administered prescription drugs. This includes Eliquis. There are no real exceptions here Original Medicare simply does not cover prescription drugs.
However, there are a variety of other options available for Medicare beneficiaries. These will vary in cost and coverage type, but lets take a look at them one by one. Remember, although the options discussed are part of Medicare, they are not part of Original Medicare. If you only have Original Medicare, you will need additional coverage to get Eliquis covered.
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Recent Articles And Updates
For older articles, please see our article archive.
The 2010 Medicare Part D $250 Donut Hole Rebate. Q1Group LLC, .
2020 Part D Income-Related Monthly Premium Adjustment. . .
2021 Medicare Part D Outlook.Q1Group LLC, .
2021 Part D Income-Related Monthly Premium Adjustment. . .
How Do Medicare Advantage Ppo Plans Work? Healthline Media, May 5, 2021, .
Analysis of Part D Beneficiary Access to Preferred Cost Sharing Pharmacies . . .
Announcement of Calendar Year 2021 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies. . .
Assistance with Paying for Prescription Drugs. Center for Medicare Advocacy, November 30, 2015, .
How Medicare Part D Works. AARP, October 2016, .
Medicare Advantage Special Needs Plans . Healthline Media, May 3, 2021, .
Kirchhoff, Suzanne M. Medicare Coverage of End-Stage Renal Disease . . .
Learn More About Your Medicare Advantage Prescription Drug Coverage Options
The cost of a Medicare Part D plan may vary from one insurance company to the next and from one location to another.
One way to learn about your Medicare prescription drug coverage options is to speak with a licensed insurance agent. You can compare Medicare Advantage plan costs in your area and find a plan that covers the prescription drugs you need.
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Additional Ways To Save Money On Eliquis
There are a few other ways to save money on Eliquis:
|Eliquis Coupon Card||Eliquis offers a $10 copay card that you can apply to every 30 day supply you purchase, for up to 24 months.|
|Free 30-Day Eliquis Trial Card||This card basically gives you a free 30-day supply of Eliquis, no matter what type of insurance you have.|
|Bristol-Myers Squibb Patient Assistance Foundation||You may qualify for additional discounts directly from Bristol-Meyers Squibb, depending on your income level. See here for more details.|
Medicare Part D Plans And Eliquis Coverage
Medicare Part D prescription drug plans are a popular way to get additional prescription drug coverage that isnt available from Original Medicare. Prescription drug plans are offered by private insurance companies but are only available to Medicare beneficiaries. They are regulated by the government to some degree, but the prices and coverage will still vary as they do under most private plans.
Part D has a maximum deductible amount of $480, so no plan will be able to include a higher deductible in 2022. This means that even if you have Part D coverage for Eliquis, you will still need to pay these costs before your coverage begins.
Premiums for Part D average around $40-45 per month, although there is a large amount of variety here, and some people will pay significantly more than this. There is also a Part D income-related monthly adjustment which will require you to pay additional fees to the United States government, depending on your income.The actual cost of Eliquis under Part D will also vary widely. However, some people pay under $50 per month for their Eliquis coverage, which is obviously much lower than the list price. If your plan covers Eliquis , then you will pay much lower than the list price, but check your plan’s details and compare plans to see how these costs apply to you. Your Part D plan may also require you to obtain prior authorization before it approves a name-brand prescription when generic alternatives are available.
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The Medicare Part D Donut Hole Coverage Gap
After 2020, Medicare Part D plans have a shrunken coverage gap, or donut hole, which represents a temporary limit on what the plan will cover for prescription drugs.
You enter the Part D donut hole once you and your plan have spent a combined $4,430 on covered drugs in 2022.
Once you reach the coverage gap, you will pay up to 25 percent of the cost of covered brand name and generic drugs until you reach total out-of-pocket spending of $7,050 for the year in 2022.
Once you reach $7,050 in out-of-pocket spending, you are out of the donut hole and enter catastrophic coverage, where you typically only pay a small copayment or coinsurance payment for the rest of the year.
Medicare Advantage Coverage For Eliquis
Medicare Advantage is a private insurance company that administers your Medicare benefits. Although these plans primarily cover Part A and Part B services, many of them also cover prescription drug expenditures to some extent.
When purchasing a Medicare Advantage plan, double-check that Eliquis will be covered. Eliquis is covered by 99% of Medicare Advantage plans, so if you require it, this is an option you should examine. Youll almost certainly be able to discover a plan that suits your needs.
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How Much Does Eliquis Cost With Medicare
The cash price of a 30-day supply of Eliquis is around $675 without insurance coverage. However, those on Medicare can access a discounted rate through your Part D plan. On average, the monthly copay for Eliquis with Part D coverage is $37, according to the medications official manufacturer site. The site also states that roughly half of people taking Eliquis, who also have Medicare coverage, pay $10 or less for the drug each month.
What Happens When Youre In The Donut Hole
When you reach the coverage gap what you pay will differ for the brand-name drugs and generic drugs covered by your Medicare plan.1
For brand-name drugs:
- Youll pay no more than 25% of the cost of the drug and 25% of the dispensing fee.
- Youll pay a discounted rate if you buy your medications at a pharmacy or through the mail.
- What you pay and what the drug manufacturer pays will count towards out-of-pocket spending that helps you eventually get out of the donut hole.
For generic drugs:
- Youll pay 25% of the price. Medicare pays 75% of the price.
- Only the amount you pay will count towards getting you out of the donut hole.
NOTE: Some plans may have coverage in the gap, so if this is true for you, you will get a discount after the plans coverage has been applied to the drugs price.
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Eliquis Coverage Through Medicare Advantage
Medicare Advantage is a way to get your Medicare benefits through private insurance companies. Although these plans primarily cover Part A and Part B services, many of them also include at least some prescription drug costs.
When you buy a Medicare Advantage plan, you should make sure that Eliquis will be covered for you. 99% of Medicare Advantage plans will cover Eliquis, so this is an option you should consider if it is a prescription you will need. You will most likely be able to find a plan that works for you.
How Much Does Generic Eliquis Cost
About Eliquis There are currently no generic alternatives for Eliquis. It is covered by most Medicare and insurance plans, but some pharmacy coupons or cash prices may be lower. The lowest GoodRx price for the most common version of Eliquis is around $511.80, 17% off the average retail price of $620.49.
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Important Safety Information & Indications
For people taking ELIQUIS for atrial fibrillation: Do not stop taking ELIQUIS without talking to the doctor who prescribed it for you. Stopping ELIQUIS increases your risk of having a stroke.
ELIQUIS may need to be stopped prior to surgery or a medical or dental procedure. Your doctor will when you should stop taking ELIQUIS and when you may start taking it again. If you have to stop taking ELIQUIS, your doctor may prescribe another medicine to help prevent a blood clot from forming.
ELIQUIS can cause bleeding, which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting.
You may have a higher risk of bleeding if you take ELIQUIS and take other medicines that increase your risk of bleeding, such as aspirin, nonsteroidal anti-inflammatory drugs , warfarin, heparin, selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors , and other medicines to help prevent or treat blood clots. Tell your doctor about all of the medicines you take, including any over-the-counter medicines, vitamins, and herbal supplements.
While taking ELIQUIS, you may bruise more easily and it may take longer than usual for any bleeding to stop.
headaches, or feeling dizzy or weak
ELIQUIS is not for patients with artificial heart valves.
ELIQUIS is not for use in people with antiphospholipid syndrome , especially with positive triple antibody testing, who have a history of blood clots.
D Appeals And Grievances
Coverage Determinations and Exceptions
All Part D plans must have an appeal process through which members can challenge a denial of drug coverage. The Part D appeals process is based on and similar to the Part C appeals process.
Denials of drug coverage by a PDP or MA-PD are called coverage determinations. For example, a coverage determination may be issued by the plan if the drug is not considered medically necessary or if the drug was obtained from a non-network pharmacy. It is necessary to have a coverage determination in order to initiate an appeal. A doctors supporting statement is not required for this type of appeal, but it may be helpful to submit one. If the request for coverage is denied, the member may proceed to further levels of appeal, including redetermination by the plan, reconsideration by an Independent Review Entity , Administrative Law Judge review, the Medicare Appeals Council , or federal district court.
One type of coverage determination is called an exception request. An exception request is a coverage determination that requires a medical statement of support in order to proceed to appeal. There are two types of exceptions that may be requested:
Formulary Exceptions This type of exception is requested because the member:
- needs a drug that is not on the plans formulary,
- requests to have a utilization management requirement waived for a formulary drug).
What to do When a Drug is Denied at the Pharmacy
The Medical Statement
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How Do You Qualify For Free Eliquis
To use your Free Trial Offer Card:Present your activated Free Trial Offer Card to your pharmacist along with your. … Eligible patients who present a Free 30-Day Trial card together with a valid 30-day prescription for ELIQUIS at participating pharmacies can receive a free 30-day supply of ELIQUIS.More items…
Understanding The Part D Coverage Stages
During the year, you may go through different drug coverage stages. There are four stages, and it’s important to understand how each impact your prescription drug costs. You may not go through all the stages. People who take few prescription drugs may remain in the deductible stage or move only to the initial coverage stage. People with many medications may move into the coverage gap and/or catastrophic stage.
The coverage stage cycle starts over at the beginning of each plan year, usually January 1st.
You pay for your drugs until you reach your plan’s deductible
If your plan doesn’t have a deductible, your coverage starts with the first prescription you fill.
You pay a small copay or coinsurance amount.
You stay in this stage for the rest of the plan year.
- Total drug costs: the amount you and your plan pay for your covered prescription drugs. Your plan premium payments arenot included in this amount.
- Out-of-pocket costs: The amount you pay for your covered prescription drugs plus the amount of the discount that drug manufacturers provide on brand-name drugs when youre in the third coverage stage — the coverage gap . Your plan premiums are not included in this amount.
*If you get Extra Help from Medicare, the coverage gap doesn’t apply to you.
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