Build Bridges to Better Coverage: Preparing for Medicare Plan Reviews

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Build Bridges to Better Coverage: Preparing for Medicare Plan Reviews

Medicare plan reviews are a critical service for both pharmacists and patients, ensuring that individuals receive the most suitable and cost-effective healthcare coverage. These reviews assist patients in selecting the best Medicare plan for their individual healthcare needs, but also enable pharmacists to maintain their patients' loyalty by ensuring their pharmacy remains in-network. We will delve into the importance of conducting Medicare plan reviews, provide examples of their benefits, and highlight the significance of providing your staff and patients with a pre-review checklist. Let's explore why Medicare plan reviews are crucial for pharmacists and patients alike. 

Why Conduct a Medicare Plan Review?

Tailor Coverage to Individual Needs

Medicare plan reviews allow pharmacists to assess the specific healthcare needs of their patients. By thoroughly reviewing the patient's current plan, prescription medications, and potential changes in treatment, pharmacists can identify coverage gaps and recommend plans that better align with their unique healthcare needs. This ensures that patients have access to the proper medications and services without unnecessary financial burdens. 

Example: A patient who recently received a new diagnosis and requires specialized medications may find that their current Medicare plan does not adequately cover the prescribed treatments. Through a plan review, the pharmacist can help the patient explore alternative plans that provide better coverage for their specific condition. 

Keep Your Pharmacy In-Network  

Conducting Medicare plan reviews enables pharmacists to ensure that the selected plan includes their pharmacy in its network of providers. When patients choose a plan that maintains the in-network status of their preferred pharmacy, pharmacists can ensure seamless prescription processing, consistent access to medications, and continued business with their patients.  

Example: If a patient enrolls in a Medicare plan that does not include their preferred pharmacy in its network, they may face higher out-of-pocket costs or be required to switch to a different pharmacy. By conducting a review, pharmacists can help patients select a plan that allows them to continue utilizing their preferred pharmacy, promoting customer satisfaction and retention. 

Maximize Cost Savings For Your Patients

Medicare plan reviews provide an opportunity to identify cost-saving strategies for patients. Pharmacists can evaluate different plan options, considering factors such as premiums, deductibles, copayments, and coverage for prescription drugs. Patients can minimize their out-of-pocket expenses by selecting the most cost-effective plan while maintaining appropriate coverage. 

Example: Through a comprehensive review, a pharmacist may discover that a patient is currently enrolled in a plan with high copayments for their frequently prescribed medications. By exploring alternative plans, the pharmacist can help the patient select a more affordable option, potentially saving them significant costs throughout the year. 

Get to Know Medicare

It's essential for patients to understand the differences between these Medicare plan types, as each provides specific coverage and benefits. Pharmacists can play a crucial role in explaining these options to patients, helping them select the most appropriate plan based on their healthcare needs, budget, and preferred providers. 

By understanding the nuances of each Medicare plan type, pharmacists can guide their patients effectively during Medicare plan reviews, ensuring they make informed decisions that align with their health requirements and maximize their coverage. 

Medicare Part A provides hospital insurance and covers inpatient hospital care, skilled nursing facility services, nursing home care (under specific conditions), hospice care, and home health services. It primarily focuses on inpatient and overnight care. 

Medicare Part B is medical insurance that covers outpatient services. It includes preventive services, such as screenings and vaccinations, diagnostic tests, doctor's appointments, durable medical equipment (DME), mental health services, and limited prescription drugs. Part B primarily focuses on services aimed at preventing, diagnosing, and treating medical conditions. 

Medicare Part C, also known as Medicare Advantage, offers a bundled plan that combines the benefits of Part A, Part B, and often Part D (prescription drug coverage). Medicare Advantage plans are offered by private insurance companies approved by Medicare. These plans may include additional benefits beyond what is covered by Original Medicare, such as vision, dental, hearing, and fitness programs. They often require patients to use network providers. 

Medicare Part D is a standalone prescription drug coverage plan that is available to Medicare beneficiaries. It helps cover the cost of prescription medications, including both brand-name and generic drugs. Part D plans are also provided by private insurance companies approved by Medicare. It is important to note that not all medications may be covered under Part D, and plans may have formularies that specify which drugs are covered. 


Navigating the Medicare enrollment process can be complex, especially for those who are approaching or have recently turned 65. Understanding the different enrollment periods and eligibility criteria is crucial to help your patients make informed decisions about their Medicare coverage. 

Those who have or will be turning 65 enter the Initial Enrollment Period (IEP), lasting 7 months. 3 months before and after their 65th birthday month.

A Special Enrollment Period (SEP) may become available in case-by-case circumstances. Scenarios for eligibility may include; moving out of a plan’s service area, relocating back to the U.S. after living abroad, employment ends resulting in the end to an employer-provided plan, etc. Please consult the Medicare website for all scenarios. 

The General Enrollment Period (GEP) typically runs from January 01-March 31 of each year. This period allows for a patient to enroll if they didn’t sign up when first eligible during their IEP and do not meet the requirements for a SEP. 

During the Annual Enrollment Period (AEP) from October 15 to December 7 of each year, anyone can make changes to their coverage and enroll in a Medicare plan 

A Checklist For Success

Medicare plan reviews can be overwhelming for patients, involving numerous considerations, deadlines, and documentation. To assist patients in navigating this process effectively, providing them with checklists is essential. 

The Importance of Providing Checklists to Patients

  • Organization and Preparedness

    Providing patients with checklists equips them with an organized framework to gather essential information and prepare for their review appointments. It helps ensure that patients come to their discussions with pharmacists well-prepared, facilitating productive conversations and informed decision-making. 

  • Empowerment and Engagement

    Offering patients a checklist empowers them to take an active role in their healthcare decisions. It encourages patients to reflect on their healthcare needs, research plan options, and gather relevant documentation. By engaging patients in the process, they become partners in their healthcare journey and are more likely to make informed choices aligned with their priorities and preferences. 

  • Enhanced Customer Experience

    Providing a checklist demonstrates pharmacists' commitment to customer service and patient care. It showcases their dedication to ensuring patients' needs are met and encourages open communication. Patients will appreciate the guidance provided and feel supported throughout the Medicare plan review process, leading to a positive customer experience and fostering long-term relationships. 

To facilitate a smooth Medicare plan review with your patients, please download our checklist pintables below.

Pharmacist Checklist  For pharmacists to help them guide patients through the Medicare plan review process.
Patient Checklist: Currently Enrolled in Medicare  For patients who are already enrolled in Medicare. 
Patient Checklist: New Enrollment/Turning 65 For patients who are approaching the age of 65 and need to enroll in Medicare for the first time.

Engage Your Patients with Outcomes

Medicare plan reviews are a valuable opportunity for pharmacists to engage with their patients and ensure they are on the best Medicare plan for their needs. With Outcomes®, pharmacists have access to powerful tools and resources to facilitate Medicare plan reviews and optimize patient care. Here's how Outcomes can help pharmacists achieve these goals: 

  • Strengthen Patient Relationships: By leveraging Outcomes' Medicare Plan Finder tool, pharmacists can serve as a trusted resource for their Medicare-eligible patients during the Open Enrollment period. With the complexity surrounding Medicare plans, patients often require guidance to navigate the available options. By offering comprehensive Medicare plan reviews, pharmacists can help patients find the plan that best meets their healthcare needs and financial goals. This level of support strengthens patient-pharmacist relationships and fosters trust and loyalty. 

  • Grow Your Pharmacy Business: Providing Medicare plan reviews positions your pharmacy as a destination for comprehensive care in your community. By attracting new high-value patients and fostering loyalty among existing patients, your pharmacy becomes a go-to resource for Medicare-related services. As Medicare patients are among the highest users of prescription drugs, establishing your pharmacy as a trusted partner in their healthcare journey can significantly contribute to the growth and success of your business. 

  • Develop Year-Round Engagement: While Medicare annual enrollment occurs once a year, Outcomes empowers pharmacists to engage with Medicare-eligible patients throughout the year. With Outcomes' Medicare Plan Finder tool, pharmacists can conduct plan reviews for patients turning 65 at any time, ensuring they receive personalized guidance tailored to their unique circumstances. This year-round engagement strengthens patient relationships and provides ongoing opportunities for education, support, and enhanced patient care. 

By leveraging Outcomes' resources and technology, pharmacists can streamline the Medicare plan review process, enhance patient satisfaction, and provide invaluable support to Medicare beneficiaries. Engaging patients through Medicare plan reviews not only benefits patients in selecting the best plans but also contributes to the success and growth of your pharmacy.