Does Medicare cover Xarelto in Oregon?

What Xarelto is used for

Xarelto is an anticoagulant (blood thinner). Its FDA label includes reducing the risk of stroke in atrial fibrillation not caused by a heart valve problem, treating and preventing DVT and pulmonary embolism, preventing clots after hip or knee replacement, and, at a low dose with aspirin, reducing the risk of major heart events in people with coronary or peripheral artery disease.

This page explains Medicare coverage only. Questions about whether Xarelto is right for you belong with your prescriber.

Which part of Medicare covers Xarelto

Xarelto is a tablet (and an oral suspension for children) taken at home, so it's a Part D drug. Different strengths treat different conditions, and a plan's formulary can list some strengths and not others, so check the exact strength you take.

Is Xarelto on Medicare's negotiated-price list?

CMS selected Xarelto in the first round of the Medicare Drug Price Negotiation Program, and its negotiated price took effect January 1, 2026. CMS then removed Xarelto from the selected list effective January 1, 2027, under the rule that a drug leaves the program once a generic or biosimilar version is approved and marketed. From 2027, the negotiated price no longer applies.

Generics and biosimilars

CMS took Xarelto out of the program because a generic rivaroxaban was approved and marketed. A generic may not come in every strength you need; your pharmacist can tell you which strengths are available as generics and whether your plan covers them.

What changes for Xarelto in 2027

Through December 31, 2026, the negotiated price applies when a Part D plan covers Xarelto. From January 1, 2027, it doesn't, and plans set 2027 formularies on their own terms. Your plan's Annual Notice of Change, mailed by September 30, says whether Xarelto stays on the formulary and on what tier. If your plan moves Xarelto or drops it, you can switch plans during Open Enrollment (through December 7, 2026), ask your prescriber about the generic, or request an exception.

What you pay for Xarelto in 2027: the out-of-pocket cap

Your cost for Xarelto depends on your plan: its deductible, the tier it puts the drug on, and whether you use a preferred pharmacy. This site doesn't list plan costs; your plan's formulary and Evidence of Coverage do. What Medicare sets for everyone with Part D is the limit:

• 2027 out-of-pocket cap: $2,400 (it was $2,100 in 2026). Once what you pay for covered Part D drugs (deductible, copays and coinsurance) reaches the cap, you pay nothing more for covered Part D drugs for the rest of 2027.
• The maximum Part D deductible for 2027 is $700. No plan can set a higher deductible.
• Only covered drugs count. If your plan doesn't cover Xarelto and you pay cash, or you use a discount card instead of your plan, that spending doesn't count toward the cap.

Spreading the cost: the Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan lets you pay your Part D drug costs in monthly bills from your plan across the calendar year instead of all at once at the pharmacy. Medicare.gov says there's no cost to participate, but it doesn't lower your drug costs; it only changes when you pay. It helps most when costs are high early in the year. To join, call your plan or use its website. More in What is the Medicare Prescription Payment Plan?

Extra Help with Xarelto

Extra Help (the Low-Income Subsidy) is a federal program that lowers Part D premiums, deductibles and copays. For 2027, CMS caps Extra Help copays for covered drugs at $5.80 for a generic and $14.40 for a brand-name drug, and some people with full Medicaid pay less. You get Extra Help automatically if you have OHP (Medicaid), a Medicare Savings Program or SSI; otherwise apply through Social Security at 1-800-772-1213 or ssa.gov/extrahelp. See Extra Help in Oregon.

Getting Xarelto covered in Oregon

If you have both Medicare and OHP, OHP doesn't pay for drugs that Part D covers. The Oregon Health Authority calls this "OHP with Limited Drug": you need a Part D plan (or a Medicare Advantage plan with drug coverage) for Xarelto, and you qualify for Extra Help automatically. See OHP and Medicare.

Oregon and Washington share Part D region 30, so standalone Part D plans are offered region-wide. For 2027, Oregon has 8 standalone Part D plans from 4 companies, plus Medicare Advantage plans with drug coverage in most counties (61 open to everyone statewide). Each plan has its own formulary, so one plan's coverage of Xarelto tells you nothing about another's.

Where you live in Oregon changes your choices. CMS data show no Medicare Advantage plan open to everyone in Grant, Harney, Lake, Umatilla or Union counties for 2027 (only employer group plans), and only a special needs plan in Curry County. If you live there, coverage for Xarelto usually comes from a standalone Part D plan alongside Original Medicare, unless you have employer or other drug coverage. Check your county's numbers on Oregon counties.

How to check whether a plan covers Xarelto

1. Write down the exact drug. Name, strength and how often you take it. A plan can cover one form of Xarelto and not another.
2. Look it up in each plan's formulary. Enter your drugs and ZIP code on PlanMatch or Medicare.gov's Plan Finder to see which plans list Xarelto and any rules.
3. Read the rules next to the drug. Prior authorization, step therapy or quantity limits mean your prescriber may need to send the plan information before it pays.
4. Check your 2027 notice. Your plan's Annual Notice of Change says whether Xarelto stays on the formulary next year. Open Enrollment runs October 15 to December 7, 2026, for coverage starting January 1, 2027.
5. Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.

If your plan doesn't cover Xarelto, you or your prescriber can ask for a coverage determination or a formulary exception. Once the plan has your prescriber's supporting statement, it generally must decide within 72 hours, or 24 hours if your prescriber says waiting could seriously harm your health. New members can usually get a one-time transition supply of a drug they were already taking while they ask for an exception or switch. See How do I appeal a Medicare denial in Oregon?

Sources

• National Library of Medicine — DailyMed: Xarelto prescribing information (FDA label)
• Medicare.gov — Drug coverage (Part D)
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
• CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold and Extra Help copays)
• Medicare.gov — Medicare Prescription Payment Plan
• Social Security — Extra Help with Medicare prescription drug plan costs
• FDA — Orange Book: approved drug products and generic equivalents
• CMS — Part D plan files record layout (PDP Region 30: Oregon, Washington)
• Oregon Health Authority — OHP and Medicare

Frequently asked questions

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