Eliquis Faces Preferred Formulary Exclusion: $13B in US Sales in Play
Aetna’s 2026 national commercial formulary delivers a harsh blow to Eliquis (apixaban), dropping the blockbuster from its preferred tier just as generic competition prepares to flood the market. Last year, the drug raked in over $13 billion in US sales for Bristol Myers Squibb and Pfizer. The trigger? Patent litigation, still unresolved, is finally giving way to generic launches from Apotex, Micro Labs, and likely others by early 2026. Behind the headlines, Aetna’s move exposes a broader industry shift: both Express Scripts and CVS Caremark are tightening their anticoagulant rosters for the same period, signaling a new chapter of cost pressure.
For Bristol Myers and Pfizer, this isn’t speculation, it’s a looming financial hit. Eliquis accounted for almost a third of Bristol Myers’ global revenue in 2023 and remains their highest-margin product by far. The pricing environment has already deteriorated: average rebate rates on Eliquis topped 35% in the last three PBM cycles, crimping net price growth even before the generic wave. With Aetna, covering roughly 12 million commercial members, setting the precedent, other payers will likely fall in line. When even half of commercial and Medicare plans remove or demote it, US net sales could shrink by $7 billion or more within two years.
Rebate benchmarks from RxPBM.ai illustrate the squeeze even more starkly. Over the past year, gross-to-net discounts for oral anticoagulants ran between 33% and 39%, leaving no real cushion for branded pricing once generics arrive. The writing is everywhere.
PBMs Shift Power: Rivaroxaban and Generics Step In
Inside PBMs, new priorities are emerging. In Aetna’s 2026 overhaul, Eliquis steps down to a higher cost tier or exits coverage altogether, while Xarelto (rivaroxaban, from Janssen) is positioned to take over much of the preferred slotting. Consider the context: Xarelto earned just under $2.8 billion in US sales last year, a fraction of Eliquis. Yet, its contract terms have become sweeter for PBMs, partly due to a more distant patent expiry, partly because Janssen has agreed to steeper rebates to remain competitive in Eliquis’s shadow.
Expect PBM preference to swing toward generics as soon as apixaban’s exclusivity is broken. Xarelto gains short-term, soaking up some of Eliquis’s displaced volume, but it won’t hold price. PBM executives at RxBenefits.ai project net branded anticoagulant costs will sink 45% to 60% across commercial books within 18 months of generic apixaban’s arrival, similar to what happened after major statin and diabetes class launches.
Minor brands like Savaysa (edoxaban) and Pradaxa (dabigatran) are unlikely to disrupt the new order. Pradaxa lost patent protection in 2021 but never recovered from adherence and safety concerns. Savaysa, with annual US sales below $300 million, isn’t big enough to shift share meaningfully. The dynamics are clear: PBMs switch from pricey brands to generics, with Xarelto as a transitional winner. Retail pharmacies, brace for a surge in generic apixaban claims and escalating plan-level rejections of branded Eliquis scripts. This is the cycle.
Pharmacy and Patient Impact: Reimbursement Turbulence Ahead
Aetna’s new formulary goes far beyond theoretical cost models. On the ground, both patients and pharmacy operations will feel the change. Historically, a preferred formulary placement meant $30 to $50 copays for a 30-day Eliquis script. Once downgraded, patient out-of-pocket costs routinely spike, $150 or more isn’t uncommon, unless switched to a generic or covered alternative like Xarelto. Early generic apixaban list prices are expected at 50% to 60% of branded Eliquis, but PBMs’ rapid adoption of Maximum Allowable Cost (MAC) lists will push reimbursement even lower. For current net price comps, RxInfo.ai keeps an updated dashboard.
Pharmacies are gearing up for a messy transition. Prescribers will be urged to move patients off Eliquis starting in early 2026. Expect a spike in prior authorizations and appeals as seen previously with statin and GLP-1 class exclusions. Many physicians, having learned from repeated PBM pivots, will proactively shift chronic care patients to generic apixaban, relying on plan advisories already circulating. Independent pharmacies, in particular, will be squeezed: generic margins, never robust, will thin further. Data suggests that within six months of exclusion, generic apixaban dispensing may exceed 85% among Aetna patients, a pattern paralleling the generic shift after Lipitor’s fall.
There’s a curious wrinkle for patients. In late 2025, some could find their out-of-pocket spending briefly rising, as plan tiers shift before generics actually land. Once generics fully arrive, average copays should drop, assuming plan sponsors share the savings. Past cycles (statins, SGLT2s) hint that PBMs may pocket a hefty slice, at least through the first generic pricing rounds. A little skepticism is warranted here.
Two Years Out: Branded Collapse and a New Anticoagulant Order
Look at the numbers and future market behavior is no mystery. Bristol Myers and Pfizer stand at the edge: Their US Eliquis franchise, once worth $13 billion annually, could shrink by half or worse if more payers follow the Aetna template. Xarelto gets a fleeting lift in volume, but only by satisfying PBMs’ demands for steeper discounts. The power dynamic has shifted. Payers and PBMs are calling the shots, not manufacturers. They’ve shown no reluctance to cut longtime favorites, a pattern that played out for GLP-1s in CVS’s 2024 exclusions. Sentiment doesn’t factor in; only rebate math and net acquisition costs.
The next act is playing out already. By late 2026, generic apixaban will likely top 70% of all US oral anticoagulant prescriptions. Xarelto and branded Eliquis will scrap for whatever is left, squeezing ever-narrower margins. The high-price oral anticoagulant era winds down for payers able to exclude, tier, and steer members. Pharmacies may count more claims, but average reimbursement will sink. Patients, too, should benefit from lower costs, eventually, but not before enduring another cycle of confusion, coverage shakeups, and unpredictable billing.
Aetna fired the first shot. Caremark and Express Scripts will respond before 2026. Expect more dominoes to fall, more pricing pressure, and a brisk, unsentimental move to generics in every corner of the market. Approach the next formulary update with eyes wide open. Real change is coming, and no manufacturer rebate is big enough to put the genie back.
