Navigating Medicare Open Enrollment: What Every Pharmacist Should Know

The Medicare Open Enrollment period is a critical time for patients and pharmacists alike. As more Baby Boomers become eligible for Medicare, the beneficiary population is expected to increase from over 65 million beneficiaries today (as of March 2023) to over 80 million beneficiaries by 2030. Now more than ever, pharmacists must take an active role during Open Enrollment by offering services that help patients understand their plan options. Equipping yourself with the right knowledge could mean a tremendous amount of money saved for both your pharmacy and patients. As you plan to help your patients with navigating their options for the coming year, here are a few things to know:

Why You Should Compare Plans

Patients are often overwhelmed by the process of choosing a Medicare plan as drug coverages vary across plans. Studies have shown that while seniors appreciate having a variety of plans to choose from, they don’t feel confident in their ability to do so and want the selection process to be easier. Because of this, patients tend to stay on their current plan despite changes in coverage, which often leaves them paying more than they should. In fact, a July 2021 study found that 94% of Medicare beneficiaries are not on the most cost-effective plan for their medications.

It’s important to articulate to your Medicare patients that the best plan option this year may not be the best one for them next year. These patients with a limited understanding of Medicare plans can benefit greatly from plan comparisons. Studies show that Medicare beneficiaries could save on average $762 a year just by switching to the lowest cost Part D plan that covers their medications. In addition to helping patients explore their plan options, switching to a plan that best fits their drug regimen, and saving money, plan comparisons are a good opportunity for you to build stronger relationships with your patients, increase retention, and drive growth. Plan comparisons also allow you to evaluate which plans are hurting your business through low reimbursements and DIR fees.

Who Your Medicare Patients Are

This may seem obvious, but it is important to know which patients are already on Medicare plans. With a high volume of patients at your pharmacy, it can be difficult to know who exactly to reach out to during Open Enrollment. But having this information will help you target your communications so your outreach to patients is relevant based on their situation. Some Medicare plan finders — including Medicare Match from EnlivenHealth — can show you the plan comparisons you’ve performed in the past so you can better track the performance of your current patients. When that plan finder integrates with your pharmacy system and imports all your patient data, you can also easily create customized handouts for each patient showing their copay on each drug, premium costs, deductible costs, total out-of-pocket cost for the year, and which phase of coverage they are on each month. As this can give your pharmacy a competitive edge, it is in your best interest to develop a system to target these patients during Open Enrollment.

Who Your Newly Eligible Medicare Patients Are

11,000 people become Medicare eligible every day. While newly eligible patients have a seven-month window to enroll in Medicare Part D, it’s important to proactively reach out to them early on. To help streamline this process, FDS Amplicare identifies which of your patients are soon approaching their 65th birthday and provides tools for you to reach out and invite them in for a free plan comparison. Offering this service helps patients better understand their options and increases the chances of your patient becoming a loyal customer — patients are 30% more likely to stay with a pharmacy that performs a plan comparison for them.

Changes to Medicare Plans for the Coming Year

Each year, the Centers for Medicare and Medicaid Services (CMS) updates rules and regulations for Original Medicare and Medicare Advantage plans. These updates affect the services that plans offer beneficiaries, making it important to stay well-informed on what coverage options may be available in the new year. For instance, CMS has added more flexibility to Medicare Advantage programs in recent years, allowing them to offer options such as increased telehealth access. The agency has also made changes that target opioid use and patients with chronic conditions.

Reimbursements for Each Plan and Associated DIR Fees

Knowing the estimated annual cost of various plan options, including the separate costs for premiums, deductibles, and copays, can help inform your patients which plan is best for them when doing a plan comparison. By knowing the reimbursements you can expect on each plan, as well as any associated DIR fees, you are able to highlight opportunities that save both the patient and your pharmacy money. Looking into these win-win opportunities is the best way that your pharmacy can take control of low reimbursements, avoid being taken advantage of by insurance companies, and thrive.

Which Plans Have Restrictions in Place

The ability to identify any restrictions can save you and your patient headaches later on when they come in to fill their prescriptions. Patients will want to know which plans cover all their drugs or require prior authorization or step therapy for certain drugs.

It’s also important to note that Medicare Advantage plans have limited doctor networks, meaning that not all plans will allow the patient to see certain doctors. If a plan has changed a patient’s provider network for the new year, they can switch to a plan that will include their current doctors during Open Enrollment, lowering their medical costs.

Formulary Changes

Formularies change from year to year. While patients may be content with their plans, it’s still important for them to reevaluate their options during Open Enrollment to account for changing formularies and costs. Customers may be unaware, for example, about how a plan’s formulary changes will affect their out-of-pocket expenses. By knowing what the major changes are, you can look into plan restrictions for different medications and find alternatives. Help patients find adequate alternative medications more suitable for their budget and increase their adherence and your revenue.


Plan comparisons not only help your patients save money, but also ensure that you and your pharmacy staff are aware of the changes in Medicare plans. And with the Medicare-eligible population only growing, the pharmacies that best understand Medicare is going to be the pharmacies that thrive.


EnlivenHealth® builds advanced patient engagement, financial management, clinical and analytics technology solutions that enable retail pharmacies and health plans to measurably improve the health of patients and members. At the same time, their intelligent digital solutions ensure the long-term health of their customers’ businesses. With the acquisitions of FDS Amplicare and MarkeTouch Media, EnlivenHealth® now offers the industry’s most comprehensive suite of SaaS technology solutions that help retail pharmacies and health plans to transform and thrive in this new era of digital-driven healthcare. Currently, more than 50,000 retail pharmacies nationwide deploy technology solutions from EnlivenHealth®, incorporating the former FDS Amplicare and MarkeTouch Media. For more information contact Nikki Miller at or 877-602-4179.