OBJECTIVES: To evaluate the cost-utility of apixaban vs warfarin in patients with atrial fibrillation (AF) from the Peruvian Social Security (EsSalud) perspective. METHODS: A validated Markov decision model was adapted from EsSalud´s perspective. For efficacy and safety inputs, the model is based on data from the ARISTOTLE trial and clinical trials of warfarin therapy for AF. Resource utilization and costing of events were estimated using a reference hospital´s billing records and validated with local experts. Costs of procedures were obtained from official EsSalud tariffs. The costs of medications were obtained from SEACE. All costs are presented at 2014 nuevos soles. A discount rate of 3.5% was used for both costs and outcomes. A cohort of 1,000 patients was modeled using a lifetime horizon. Probabilistic sensitivity analysis (PSA) as well as univariate sensitivity analyses were performed. RESULTS: The following outcomes were estimated: Total Ischemic Stroke (non-fatal mild, non-fatal moderate, non-fatal severe, fatal) apixaban: 147 vs. warfarin: 161. Total hemorrhagic stroke (non-fatal mild, non-fatal moderate, non-fatal severe, fatal) apixaban: 14 vs. warfarin 26. Other major bleeds (non-fatal GI bleeds, non-fatal non ICH or non GI related major bleeds, fatal): apixaban: 66 vs. warfarin: 85. Warfarin therapy resulted in a quality-adjusted life expectancy of 6.19 years at a cost of S/. 14,744. Treatment with apixaban led to a quality-adjusted life expectancy of 6.50 years at a cost of S/. 27,473. The cost-utility ratio was calculated at S/.  41,296 per QALY. Our findings were robust in univariate sensitivity analyses varying model inputs across plausible ranges. In Monte Carlo analysis, apixaban was cost-effective in 70% of simulations using the recommended threshold for WHO of 3 GDP per capita. CONCLUSIONS: Apixaban is a cost-effective alternative relative to warfarin for secondary stroke prevention in patients with AF treated at EsSalud.