Eliquis (apixaban, Bristol Myers Squibb/Pfizer) and Xarelto (rivaroxaban, Janssen/Johnson & Johnson) are the two dominant direct oral anticoagulants (DOACs) in the United States. Together, they account for the vast majority of novel blood-thinner prescriptions. Both were among the first 10 drugs selected for Medicare price negotiation under the Inflation Reduction Act, with negotiated prices taking effect January 1, 2026. Despite sharing the same drug class (factor Xa inhibitors), they differ in dosing frequency, renal clearance, FDA-indicated uses, bleeding risk profiles, and cost trajectories.
This comparison is for access teams, formulary decision-makers, and prescribers who need to understand the practical differences when navigating coverage and clinical choice.
Short answer
| Eliquis (apixaban) | Xarelto (rivaroxaban) | |
|---|---|---|
| Drug class | Direct factor Xa inhibitor | Direct factor Xa inhibitor |
| FDA indications | Stroke prevention in NVAF, DVT treatment, PE treatment, DVT prophylaxis (hip/knee replacement), VTE reduction in pediatric patients | Stroke prevention in NVAF, DVT treatment, PE treatment, DVT prophylaxis (hip/knee replacement), VTE reduction in hospitalized acutely ill adults, VTE reduction in CAD, VTE reduction in PAD, VTE in pediatric patients, thromboprophylaxis post-Fontan |
| Dosing frequency | Twice daily | Once daily (for most indications); twice daily for initial DVT/PE treatment |
| Renal clearance | ~27% | ~36% (higher renal dependence) |
| Dose adjustment for renal impairment | Yes (2.5 mg BID if ≥2 of: age ≥80, weight ≤60 kg, Cr ≥1.5 mg/dL) | Yes (15 mg daily for CrCl 15–50 mL/min in NVAF) |
| IRA Medicare negotiated price (2026) | $231/month (56% below 2023 list) | $197/month (estimated, lower than 2023 list) |
| 2026 out-of-pocket cap (Part D) | $2,100/year | $2,100/year |
| Generic availability | Approved but blocked by patent; expected April 2028 | Generic ANDA approvals granted; only 2.5 mg commercially available |
| Commercial coverage | Widely covered; Tier 2 on most formularies | Widely covered; Tier 2 on most formularies |
| PA required | Generally no (for standard indications) | Generally no (for standard indications) |
FDA-approved indications
Shared indications
Both Eliquis and Xarelto are approved for:
- Reduction of risk of stroke and systemic embolism in nonvalvular atrial fibrillation (NVAF)
- Treatment of deep vein thrombosis (DVT)
- Treatment of pulmonary embolism (PE)
- Reduction in the risk of recurrent DVT and PE following initial treatment
- Prophylaxis of DVT following hip or knee replacement surgery
- Treatment of VTE and reduction in risk of recurrent VTE in pediatric patients
Xarelto-only indications
Xarelto has additional FDA indications that Eliquis does not:
- VTE prophylaxis in hospitalized acutely ill adults at risk for thromboembolic complications not at high risk of major bleeding
- Reduction in risk of major cardiovascular events (cardiovascular death, MI, stroke) in adults with coronary artery disease (CAD)
- Reduction in risk of major thrombotic vascular events (cardiovascular death, MI, stroke, acute limb ischemia) in adults with peripheral artery disease (PAD)
- Thromboprophylaxis in pediatric patients aged 2+ after the Fontan procedure
The CAD and PAD indications are unique to Xarelto. For patients who need anticoagulation for both atrial fibrillation and established coronary or peripheral artery disease, Xarelto can cover both with a single prescription.
Dosing comparison
Stroke prevention in NVAF
| Eliquis | Xarelto | |
|---|---|---|
| Standard dose | 5 mg twice daily | 20 mg once daily (with evening meal) |
| Reduced dose | 2.5 mg twice daily (if ≥2 of: age ≥80, weight ≤60 kg, Cr ≥1.5 mg/dL) | 15 mg once daily (CrCl 15–50 mL/min) |
| Food requirement | None | Take with evening meal |
| Renal avoidance | Not recommended if CrCl <15 mL/min or on dialysis (limited data) | Avoid if CrCl <15 mL/min |
DVT/PE treatment
| Eliquis | Xarelto | |
|---|---|---|
| Initial phase | 10 mg twice daily for 7 days | 15 mg twice daily for 21 days |
| Maintenance | 5 mg twice daily | 20 mg once daily (15 mg if CrCl 15–50 mL/min) |
| Extended prophylaxis | 2.5 mg twice daily (after ≥6 months treatment) | 10 mg once daily (after ≥6 months treatment) |
Key clinical differences
Dosing frequency: Eliquis is taken twice daily; Xarelto is once daily for most indications. Once-daily dosing may improve adherence but produces wider peak-trough drug level variability.
Renal considerations: Eliquis has lower renal clearance (~27% vs ~36% for rivaroxaban). For patients with advanced CKD (stage 4–5), Eliquis is generally preferred. Observational studies (AJKD 2024, Fu et al.) found that compared with apixaban, rivaroxaban was associated with a higher rate of major bleeding driven by extracranial bleeding (primarily GI bleeding) in patients with atrial fibrillation and advanced CKD.
Food requirement: Xarelto must be taken with food for the 15 mg and 20 mg doses to ensure adequate absorption. Eliquis has no food requirement.
Bleeding risk evidence
Multiple observational studies and real-world analyses have compared bleeding risk between the two DOACs:
- FDA Sentinel database analysis (Bradley et al., 2022, 2024): In patients ≥65 with NVAF, rivaroxaban was associated with significantly higher rates of major GI bleeding (HR 2.35, 95% CI 2.11–2.61) and major extracranial bleeding (HR 2.33, 95% CI 2.11–2.58) compared with apixaban.
- COBRRA trial (NEJM): Assessed bleed risk between agents in patients with VTE; those treated with Eliquis had lower rates of bleeding.
- Advanced CKD population: Comparative studies show apixaban is associated with lower major bleeding risk than rivaroxaban in patients with atrial fibrillation and stage 4–5 CKD.
In practice, these bleeding risk differences influence payer and prescriber preference, particularly for older patients and those with renal impairment.
IRA Medicare price negotiation
Both Eliquis and Xarelto were among the first 10 drugs selected for Medicare price negotiation under the Inflation Reduction Act. Negotiated prices took effect January 1, 2026.
| Eliquis | Xarelto | |
|---|---|---|
| 2023 list price (30-day supply) | ~$521 | ~$516 |
| 2026 negotiated Medicare price | ~$231/month | Lower than 2023 list (CMS-negotiated) |
| Price reduction | 56% | Significant (exact % varies by source) |
| Applies to | Medicare Part D beneficiaries only | Medicare Part D beneficiaries only |
Important: The negotiated prices apply to the Medicare program overall, not directly to individual patient cost-sharing. Individual patients may or may not see reduced copays, depending on their Part D plan's benefit structure. The $2,100 annual out-of-pocket cap for 2026 provides a ceiling regardless.
Medicare spent nearly $18.3 billion on Eliquis for nearly 4 million beneficiaries in 2023, making it the single most costly Part D drug. Both drugs must now be included on all Medicare Advantage and Part D plan formularies.
Coverage by payer type
Commercial insurance
Both Eliquis and Xarelto are widely covered on commercial formularies, typically at Tier 2 (preferred brand) with quantity limits.
| Payer | Eliquis | Xarelto |
|---|---|---|
| UnitedHealthcare | Tier 2; QL (60 tabs of 5 mg/30 days) | Tier 2; QL (30 tabs of 20 mg/30 days) |
| OptumRx | Tier 2; QL | Tier 2; QL |
| Humana | Tier 3 (both) | Tier 3 (both) |
| Aetna | Preferred; Pradaxa excluded in favor of Eliquis/Xarelto/warfarin | Same |
| EmblemHealth | Both on formulary with quantity limits | Both on formulary with quantity limits |
Prior authorization is generally not required for standard FDA indications. Step therapy may apply for newer anticoagulants like Savaysa (edoxaban).
Medicare Part D
Both Eliquis and Xarelto must be covered by all Part D plans under the IRA's negotiation requirements. The $2,100 annual out-of-pocket cap applies.
| Factor | Eliquis | Xarelto |
|---|---|---|
| Formulary status | Required (IRA selected drug) | Required (IRA selected drug) |
| Average monthly cost (Medicare) | ~$51/month (post-negotiation) | Varies by plan |
| Annual OOP cap | $2,100 | $2,100 |
| MPPP available | Yes (monthly payment option) | Yes (monthly payment option) |
Medicaid
Both drugs are covered by state Medicaid programs. Copays are typically minimal ($1–$4 per fill). PA may be required in some states.
Generic availability
Eliquis
Generic apixaban was approved by the FDA in 2019 but remains blocked by patent litigation. Generic Eliquis is not expected to be available in U.S. pharmacies until at least April 2028. Until then, only brand-name Eliquis is sold domestically.
Xarelto
Generic rivaroxaban has received FDA approval from multiple manufacturers. Several ANDA holders have received tentative or full approval for 10 mg, 15 mg, and 20 mg strengths. However, commercial launch of most strengths remains blocked by patent protections — only the 2.5 mg generic rivaroxaban (from Lupin and Taro) is currently on the U.S. market as of early 2026. The higher-strength generics have regulatory approval but are not yet available in pharmacies pending patent resolution.
The earlier FDA approval of generic rivaroxaban (compared with Eliquis generics) could eventually shift formulary preferences toward Xarelto (or its generics) for cost reasons, even as Eliquis maintains a clinical advantage in bleeding risk. However, the timeline for commercial availability of higher-strength generics remains uncertain.
Cost comparison
| Eliquis | Xarelto | |
|---|---|---|
| List price (30-day supply) | ~$520–$530 | ~$510–$520 |
| Medicare negotiated price (2026) | ~$231/month | Lower than 2023 list |
| Commercial copay (average, AF) | ~$48/month | Varies by plan |
| Eliquis 360 Support copay card | As low as $0/month (commercially insured) | N/A |
| Xarelto copay card | N/A | Manufacturer support available |
| SingleCare discount | ~$156 for 28 tablets (5 mg) | Varies |
| Generic expected | April 2028 | 2.5 mg available; 10/15/20 mg pending patent resolution |
What changed in 2026
- IRA negotiated prices took effect January 1, 2026: Both Eliquis and Xarelto have new, lower Medicare prices. Individual patient savings depend on Part D plan design.
- $2,100 annual Part D out-of-pocket cap: Applies to all Part D drugs including both DOACs.
- Medicare Prescription Payment Plan (MPPP): Patients can elect to pay out-of-pocket costs in monthly installments rather than lump sums.
- Generic rivaroxaban ANDA approvals: Several manufacturers have received FDA ANDA approval for generic rivaroxaban tablets (10 mg, 15 mg, 20 mg), though commercial availability remains limited to the 2.5 mg strength as of early 2026. Wider availability of higher strengths depends on patent litigation outcomes.
- Supply chain adjustments: Some pharmacies reported intermittent stock-outs of Eliquis in early 2026 as the distribution chain adapted to the new Medicare pricing structure.
What to monitor
- Generic rivaroxaban market entry: Monitor for broader commercial availability of 10/15/20 mg generic rivaroxaban and PBM formulary shifts that could prefer generic rivaroxaban over brand Eliquis.
- Generic apixaban timeline: The April 2028 expected launch date could shift based on patent litigation outcomes.
- IRA expanded negotiation: Monitor whether DOACs are re-selected for future negotiation rounds or whether additional cardiovascular drugs enter the program.
- BALANCE model for Medicare GLP-1s: The BALANCE model (originally scheduled for 2027) was paused; if it moves forward, it could affect overall Part D benefit design.
- New anticoagulant approvals: Monitor for any new factor Xa inhibitors or alternative anticoagulants that could shift formulary positioning.
- Real-world DOAC comparative data: Ongoing observational studies continue to inform the bleeding risk and effectiveness comparison between apixaban and rivaroxaban.
Sources
- FDA, Eliquis prescribing information: https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/202155s039s040lbl.pdf
- FDA, Xarelto prescribing information: https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/215859s007lbl.pdf
- AARP, First Medicare-Negotiated Drug Prices Debut in 2026: https://www.aarp.org/medicare/first-medicare-negotiated-drug-prices-debut/
- Medicare Rights Center, Negotiated Prices Take Effect for Ten Drugs in 2026: https://www.medicarerights.org/medicare-watch/2025/10/09/negotiated-prices-take-effect-for-ten-drugs-in-2026
- HHS ASPE, Medicare Prices Negotiated for 2026: https://aspe.hhs.gov/reports/medicare-prices-negotiated-2026
- KFF, Key Facts About Medicare Drug Price Negotiation: https://www.kff.org/medicare/key-facts-about-medicare-drug-price-negotiation/
- GoodRx, What Medicare Drug Price Negotiation Means for You: https://www.goodrx.com/insurance/medicare/drug-price-negotiation
- SingleCare, Eliquis generic availability: https://www.singlecare.com/blog/eliquis-generic/
- Drugs.com, Generic Xarelto Availability: https://www.drugs.com/availability/generic-xarelto.html
- Bradley et al. Major Bleeding Among Older Adults Treated with Direct Oral Anticoagulants. FDA Sentinel System. 2022, 2024.
- Fu EL et al. Comparative Safety and Effectiveness of Warfarin or Rivaroxaban Versus Apixaban in Patients With Advanced CKD and Atrial Fibrillation. AJKD 2024. DOI: 10.1053/ajkd.2023.08.017
- UnitedHealthcare, 2026 Prescription Drug List: https://www.uhcprovider.com/content/dam/provider/docs/public/resources/pharmacy/commercial-pdl-jan-2026.pdf
