DOAC access landscape: Eliquis, Xarelto, Pradaxa, and Savaysa in 2026

Direct oral anticoagulants (DOACs) — also called novel oral anticoagulants (NOACs) or target-specific oral anticoagulants — have largely replaced warfarin for most nonvalvular atrial fibrillation (AF) and venous thromboembolism (VTE) indications. Four DOACs are FDA-approved in the US: Eliquis (apixaban), Xarelto (rivaroxaban), Pradaxa (dabigatran), and Savaysa (edoxaban). Two of them — Eliquis and Xarelto — are among the ten drugs with IRA-negotiated Medicare prices effective in 2026, and generic competition is approaching.

This landscape guide is for prescribers, access teams, pharmacists, and payer professionals who need a cross-DOAC view of coverage, prior authorization, cost trends, and upcoming market changes.

FDA-approved DOACs at a glance

Common FDA-approved indications

Formulary placement and prior authorization

DOACs are among the most widely used specialty-tier drugs in the US. Most commercial and Medicare plans cover at least one DOAC without step therapy, but prior authorization is common.

Commercial insurance

A 2023 Oregon Division of Financial Regulation analysis found:

• Eliquis: approximately 36.5% of plans required prior authorization; 0% required step therapy; 34.3% placed it on a non-preferred tier; no plans excluded it
• Xarelto: approximately 35.5% of plans required prior authorization; 0% required step therapy; 0% placed it on a non-preferred tier; no plans excluded it

Medicare Part D

Both Eliquis and Xarelto are among the ten drugs with IRA-negotiated Medicare prices effective January 1, 2026:

Key Medicare access points:

• All Medicare Part D and Medicare Advantage drug plans must cover both Eliquis and Xarelto (IRA requirement for negotiated drugs)
• The Part D out-of-pocket cap is $2,100 in 2026 (up from $2,000 in 2025)
• Prior authorization may still apply but cannot result in coverage denial for FDA-approved indications of negotiated drugs
• Generic dabigatran (Pradaxa) is available at lower cost tiers for patients who can use a direct thrombin inhibitor

Medicaid

State Medicaid programs generally cover DOACs with prior authorization. Common criteria include:

• Documented diagnosis (AF, DVT, PE, or post-surgical prophylaxis)
• Clinical rationale for DOAC selection over warfarin
• Some states require trial of warfarin before covering a DOAC (though this is increasingly rare)
• Pradaxa (generic dabigatran) may be placed on Tier 1 as a generic option

Generic competition timeline

The DOAC market is approaching a generational shift:

The FDA approved the first generic apixaban (Eliquis) applications in December 2019, but patent settlements between BMS/Pfizer and generic manufacturers delayed US market entry to April 2028. In Europe and Canada, generic apixaban has been available since 2022, creating a significant pricing disparity with the US.

Eliquis vs. Xarelto: access differences

While both are factor Xa inhibitors and covered for most overlapping indications, there are practical access differences:

Prior authorization checklist

When submitting prior authorization for any DOAC, prepare:

1. Diagnosis documentation: ICD-10 code (I48.x for AF, I82.90 for DVT, I26.9 for PE, Z96.641/Z96.642 for post-joint replacement)
2. Clinical rationale: Specify indication, duration of therapy, and why a DOAC is preferred over warfarin
3. Renal function: Current creatinine clearance (CrCl) — critical for dose selection and product eligibility
4. Contraindications check: Document absence of prosthetic heart valves, hemodynamically significant mitral stenosis, or other contraindications
5. Concurrent medications: Note antiplatelet agents, NSAIDs, or interacting drugs
6. Prior therapy: If applicable, document prior anticoagulant use, INR management issues, or intolerance to warfarin

Common ICD-10 codes for DOAC prior authorization:

Cost and copay programs

Commercial copay programs

Patient assistance

Each manufacturer offers patient assistance programs for qualifying uninsured or underinsured patients. Income thresholds and eligibility vary. Eliquis and Xarelto programs are available through the manufacturers' respective websites.

Cash pricing (30-day supply)

Health equity and access disparities

DOAC access is not evenly distributed across patient populations. Oregon PDAB analyses of Eliquis and Xarelto identified significant disparities:

• Black, Hispanic, and American Indian/Alaska Native patients are consistently less likely than white patients to receive DOAC therapy despite comparable clinical indications for stroke prevention in AF or VTE treatment
• Economically and socially marginalized patients are more likely to be managed with warfarin even when guidelines indicate DOACs could yield better outcomes
• Apixaban prescriptions are more frequently rejected by payers for minority patients, suggesting formulary barriers disproportionately affect underserved populations
• Provider bias, insurance formulary restrictions, and structural social determinants all contribute to these inequities
• Observational data suggests apixaban has a lower risk of major and gastrointestinal bleeding compared to rivaroxaban and dabigatran, which may be particularly important for patients with limited access to monitoring or follow-up care

Access teams and payer professionals should consider these disparities when designing formulary policies and prior authorization criteria. Requiring step therapy through warfarin or imposing restrictive PA criteria may widen existing gaps.

What to monitor next

• Eliquis generic entry (April 2028): The largest generic drug launch in US history by prescription volume. Payers are expected to rapidly shift formularies to generic apixaban. Prepare for tier changes and potential step therapy requirements starting in 2028
• IRA second round negotiations: CMS is negotiating prices for 15 additional Part B and Part D drugs for 2028 implementation, which could include additional cardiovascular agents
• CMS interoperability rule: Proposed 2026 rules would require payers to share detailed PA decision data through APIs, potentially streamlining the PA process starting October 2027
• Pradaxa generic uptake: As the first generic DOAC available, dabigatran uptake patterns will signal how payers and prescribers will respond to Eliquis and Xarelto generics
• New DOAC pipeline: No new DOACs are in late-stage development, but fixed-dose combinations and reversal agent improvements may affect the landscape
• Medicare Part D OOP cap changes: The $2,100 cap in 2026 will significantly reduce patient costs for DOACs, particularly for Eliquis and Xarelto under negotiated prices

Disclaimer

This article is for informational purposes only and does not constitute medical advice. Coverage, formulary placement, and prior authorization criteria vary by plan and change frequently. Always verify current requirements with the patient's specific payer.

Sources

• CMS. Medicare Drug Price Negotiation Program: Selected Drugs for Initial Price Applicability Year 2026. https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf
• KFF. Key Facts About Medicare Drug Price Negotiation. https://www.kff.org/medicare/key-facts-about-medicare-drug-price-negotiation
• Oregon Division of Financial Regulation. Eliquis plan design analysis. https://dfr.oregon.gov/pdab/Documents/Eliquis.pdf
• Oregon Division of Financial Regulation. Xarelto plan design analysis. https://dfr.oregon.gov/pdab/Documents/Xarelto.pdf
• Cigna. Anticoagulants — Eliquis Prior Authorization Policy. https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_311_coveragepositioncriteria_%20anticoagulants_eliquis_pa.pdf
• ASPE/HHS. Medicare Prices Negotiated for 2026 Compared to List and US Net Prices. https://aspe.hhs.gov/reports/medicare-prices-negotiated-2026
• FDA. First Generic Drug Approvals. https://www.fda.gov/drugs/drug-and-biologic-approval-and-ind-activity-reports/first-generic-drug-approvals
• Drugs.com. Generic Eliquis Availability. https://www.drugs.com/availability/generic-eliquis.html
• PrescriberPoint. Eliquis and Xarelto prior authorization resources. https://prescriberpoint.com/therapies/eliquis-e948162/prior-authorization-forms
• AJMC. Biosimilar Interchangeability and Substitution in the US. https://www.ajmc.com/view/biosimilar-interchangeability-and-substitution-in-the-us-what-comes-next-