What if a patient on Eliquis (apixaban) can't afford the cost?

Cost Barriers to Apixaban (Eliquis): Practical Solutions

When a patient cannot afford apixaban, switch to warfarin as the most cost-effective alternative, which costs approximately $1.00-$2.99 per day compared to apixaban's $15.56 per day. 1

Immediate Cost-Saving Alternatives

First-Line Alternative: Warfarin

• Warfarin remains the least expensive anticoagulant option at approximately $1.00-$2.99 per day for unfractionated heparin bridging, with long-term warfarin costs being minimal 1
• While warfarin requires INR monitoring and has dietary restrictions, it provides effective anticoagulation when cost is prohibitive 1
• Cost-effectiveness analyses consistently show warfarin as the least costly option ($46,241 lifetime cost vs. higher costs for DOACs), though with slightly lower quality-adjusted life years 2

Financial Assistance Programs

• Patient out-of-pocket costs vary markedly depending on insurance coverage and whether the medication is covered under medical or pharmacy benefits 1
• Patients should be made aware of manufacturer financial assistance programs and patient assistance foundations 1
• Different pharmacies may offer substantially different prices even with the same insurance plan, so price comparison is essential 1

Alternative DOAC Options if Warfarin is Unsuitable

Consider Other DOACs Based on Cost

• Edoxaban costs $14.56 per day (slightly less than apixaban's $15.56) and may be covered differently by insurance 1
• Rivaroxaban costs $15.69 per day for maintenance dosing, comparable to apixaban 1
• Dabigatran pricing varies but may have different insurance coverage or assistance programs 1

Insurance Coverage Considerations

• Coverage may differ between medical and pharmacy benefits, with different cost-sharing arrangements 1
• Patients should verify which specific products are preferred or covered by their particular insurance plan 1
• Generic alternatives are not yet available for apixaban, limiting cost-reduction options through substitution 1

Clinical Decision-Making Framework

When Warfarin is Appropriate

• For patients with good medication adherence and ability to attend regular INR monitoring, warfarin provides effective anticoagulation at minimal cost 1
• Warfarin may be preferred in patients without contraindications to vitamin K antagonists 1
• Centers with excellent time in therapeutic range (TTR) management can achieve outcomes comparable to DOACs with warfarin 3

When to Prioritize DOAC Despite Cost

• Patients at high risk for intracranial hemorrhage benefit significantly from DOACs over warfarin, as all DOACs show lower ICH rates 1
• Those with documented poor INR control or inability to attend monitoring appointments 3
• Patients with multiple drug interactions or dietary restrictions that make warfarin management difficult 1

Cost Discussion Best Practices

Shared Decision-Making Approach

• Clinicians should discuss the use of less expensive alternatives when two or more treatment options are comparable in benefits and harms 1
• Present concrete cost differences: warfarin at ~$2-3/day versus apixaban at ~$15.56/day represents approximately $5,000 annual difference 1
• Higher patient out-of-pocket costs are a documented barrier to initiating and adhering to recommended treatments 1

Important Caveats

• Never compromise anticoagulation entirely due to cost - untreated thromboembolic disease carries substantial morbidity and mortality risk 1
• The cost of thrombotic complications far exceeds medication costs - preventing stroke or VTE recurrence is cost-effective even with more expensive agents 1
• Consider that hospitalization costs for complications dwarf medication costs - DOACs may reduce overall healthcare expenditure despite higher drug costs 1

Special Population Considerations

• For cancer patients with VTE, enoxaparin may be preferred over any oral agent and costs $3.49-$12.21 per day depending on dosing 1
• In patients with severe renal impairment, medication choices become more limited regardless of cost 1
• Patients with gastric or gastroesophageal tumors are at increased hemorrhage risk with DOACs, making LMWH potentially preferable despite cost 4