What’s the Buzz

Updated July 10, 2022

Effective July 1st, 2022, CVS Health added Eliquis back on its national formulary. Following the removal of Eliquis from its formulary in January of this year, patients on Eliquis had two options—pay for Eliquis out-of-pocket or switch to Xarelto, another blood thinner in the same class. Although Xarelto and Eliquis are both blood thinners in the same drug class, each has unique features—please read below to learn more about these two popular anticoagulants.

In addition to helping alleviate the financial burden, CVS re-adding Eliquis to its formulary is excellent news for patients and their families. This decision relieves concern of potential adverse effects on patients’ overall health and wellness caused by this formulary change.

What does it mean when a health plan excludes a medication from its formulary?

You may have heard the terms non-formulary medications, excluded drugs, or formulary exclusion list - they are interchangeable and mean that certain medicines are not covered by a pharmacy benefit manager (PBM), health plan, or insurance company because such medications are deemed not “medically necessary.” Your health plan encourages you, the member, to use the “formulary drugs” or the “covered preferred alternatives” (drugs in the same therapeutic class with a very similar mechanism of action in treating certain medical conditions). 

How do health plans determine which drugs to include in their formulary and why do changes occur?

A health plan may want you to use a different medication in the same therapeutic class because one drug may have a better side effect profile or be more effective than the other. In some cases, a drug is removed from the formulary because the manufacturer pulls it from the market or the FDA deems it to be unsafe. However, cost is one of the primary reasons behind annual formulary changes.

Health plans try to reduce costs by making the copayment higher for more expensive drugs or leave them off their formulary entirely. Sometimes, the health plan negotiates discounts with the costly drug’s maker by excluding the competing drug from their formulary.

CVS Caremark formulary change: Eliquis excluded from formulary as of 2022

As of 2022, CVS Caremark (part of CVS Health) has excluded Eliquis from its formulary - this does not mean your physicians cannot prescribe Eliquis (apixaban) to you; it means that Eliquis is no longer counted toward your yearly deductible and that CVS Caremark is no longer paying the product. Due to this formulary change, Xarelto (rivaroxaban) is now the formulary’s direct oral anticoagulant (DOAC) instead of Eliquis. This is known as “non-medical switching,” when a prescription is filled by a medication other than the one prescribed without the consent of the patient and the prescribing clinicians.

The American Heart Association and The American College of Cardiology oppose therapeutic substitution in general, citing that this practice leads to poor patient outcomes as it “may result in the patient receiving a drug that doesn’t work well enough, produces life-threatening toxicity, or interacts dangerously with other drugs the patient is taking.” According to The National Blood Clot Alliance (NBCA), changing an anticoagulant mid-treatment for non-medical reasons can potentially introduce a new source of variability to otherwise stable patients.

What does this change mean for CVS Caremark members?

Xarelto is now the only direct oral anticoagulant (DOAC) that CVS Health covers. CVS Caremark members now have two choices:

• Transition to the alternative brand, Xarelto
• Pay 100% out-of-pocket for Eliquis

What is Xarelto?

Xarelto is an anticoagulant or a blood thinner. The FDA approves Xarelto for blood clot prevention and treatment or heart conditions. Xarelto is prescribed for patients with venous thromboembolism (VTE), which are blood clots in the veins; though, Xarelto is also effective for the treatment of deep vein thrombosis (DVT) - blood clots in the legs, or pulmonary embolism (PE) - blood clots in the lungs.  

Blood clots can develop when you do not move around much; for example, when you are sick or have just had surgery. Xarelto is also used in people with atrial fibrillation (A-Fib), where the heart beats irregularly, leading to blood clots in the heart. In people who have been receiving treatment for blood clots for at least six months, Xarelto can be given to reduce the risk of DVT or PE. 

How are Xarelto and Eliquis similar?

Both Eliquis and Xarelto are direct oral anticoagulants (DOAC) only available as brand names. Unlike warfarin, Eliquis and Xarelto do not require continuous blood monitoring for INR (International Normalized Ratio) to see how thick or thin your blood is. Similar to Eliquis, Xarelto is a Factor Xa inhibitor; it blocks factor Xa, an enzyme needed for blood to clot.

Both Eliquis and Xarelto are considered the “next-generation blood thinners,” compared to the older, more commonly-known, more inexpensive counterpart - vitamin K antagonist (warfarin) or low-molecular-weight heparin (enoxaparin).

Eliquis and Xarelto are only available by prescription; there is no generic available for either drug.

What are the differences between Xarelto and Eliquis?

The key difference between Xarelto and Eliquis is that Xarelto has two additional indications:

• Xarelto is prescribed for the prevention of VTE and VTE-related death during hospitalization and after discharge in adult patients admitted for acute illnesses. It is also used for patients at risk of thromboembolic complications due to restriction of mobility and other VTE risk factors. However, Xarelto is not recommended for patients at high risk of bleeding.
   
• Xarelto can be given with aspirin to lower the risk of cardiovascular events such as stroke, heart attack, and death in patients with coronary artery disease (CAD - reduced blood flow to the heart) or peripheral artery disease (PAD - decreased blood flow to the legs).

Lastly, Elilquis is manufactured by Bristol-Myers Squibb and Xarelto by Janssen Pharmaceuticals.

How can CVS Caremark members best adapt to this change?

This formulary change is no doubt problematic for patients stable on their anticoagulant medicine who have to switch medications for non-medical reasons. As long as you are not at a high risk for bleeding, Xarelto may be a good option if you are admitted and then discharged from the hospital for an acute illness and have restricted mobility leading to an increased risk of thromboembolism. Eliquis is a better option for those at high risk of bleeding. If you are affected by this change, talk to your care team to learn more about Xarelto or explore other treatment options and modalities, if available. 

BuzzRx offers a free prescription discount card and savings coupons. You can get Eliquis at lower prices if you decide to stay on the medication. BuzzRx discount cards can be used to save on drugs at all participating pharmacies, including CVS pharmacy, Walgreens, and Rite Aid, among other major chains

References:

https://www.ahajournals.org/doi/10.1161/CIR.0b013e31822d97d5

https://nclnet.org/common_therapeutic_drug_substitutions/

https://payorsolutions.cvshealth.com/insights/2022-cvs-caremark-formulary-updates

https://ppahs.org/2021/12/cvs-caremark-formulary-exclusion

Product Information: XARELTO(R) oral tablets, rivaroxaban oral tablets. Janssen Pharmaceuticals Inc (per FDA), Titusville, NJ, 2019.