Blog Post

Medicare Open Enrollment is Here – How Pharmacists Can Help Patients Navigate their Options

Introduction

Medicare Open Enrollment season arrived right on time in mid-October and will run through December 7. If history is any guide, the period may see more than 10 million Medicare beneficiaries make a coverage change, with millions more considering a change. Pharmacists have an important role in helping patients understand their options and deciding on their best course going forward.

What is Medicare Open Enrollment and Why Does It Matter for Pharmacies?

Open Enrollment occurs annually from October 15-December 7. During this time, enrollees have an opportunity to switch to a different plan that better meets their precise medical and prescription drug coverage needs. The importance of this period is significant, given the importance of the Medicare community both in terms of volume and cost expenditures.

With regard to size, the Centers for Medicare & Medicaid Services (CMS) reports 69 million Americans are currently enrolled in a Medicare plan. Of that number, 51% are enrolled in Medicare Advantage and “Other Health Plans,” with the remaining 49% enrolled in regular Medicare plans.

81% of beneficiaries are enrolled in a Medicare Part D plan, which provides coverage for prescription drugs.

And with regard to Medicare’s financial importance, CMS reports that during 2023, total Medicare spending exceeded $1 trillion, and accounted for 21% of all U.S. healthcare spending.

Most beneficiaries will not make a change during Open Enrollment, but given the size of the Medicare pool, even a small percentage shift can have a sizeable impact. Analysis by the Commonwealth Fund found that roughly 15% of Medicare beneficiaries switched coverage during the past two years. With 69 million Americans enrolled in Medicare plans, this amounts to roughly 10 million enrollees making a change.

The Commonwealth Fund identified additional trends that include:

Among those who made a change, 49% switched from one Medicare Advantage plan to another, while 35% switched from traditional Medicare to a Medicare Advantage plan.

Among those who did not make a change, 6% (3.5 million) reported they had wanted to make a change but hadn’t done so. Almost 80% (47 million) said they were not interested in making a change.

Why Do People Change Their Medicare Coverage?

There are many reasons why a Medicare beneficiary might want to make a change in coverage, with cost and coverage typically topping the list. Analysis by Commonwealth Fund found top reasons that include:

Desire to reduce costs.

Among Medicare Advantage patients who made a switch, 31% said they did so to lower their premiums and copayments, with 28% citing a desire to limit out-of-pocket expenses. Among traditional Medicare patients, 51% cited cost.

Desire to improve benefits.

Among Medicare Advantage patients, 48% said they made a change as a way to “get more benefits covered,” compared with 17% of beneficiaries enrolled in traditional Medicare.

Better access to doctors and providers.

16% of Medicare Advantage enrollees said they made a change to improve access to healthcare providers, compared with 10% of traditional Medicare patients.

Changes in employer coverage.

Nearly 20% of both Medicare Advantage and traditional Medicare patients made a change due to employer or union coverage issues. Others said a change was necessary because their current plan was no longer offered, or because they had lost coverage.

External opinions.

The Commonwealth Fund research also noted the role of friends and family in influencing a beneficiary’s decision to change plans, along with advice from insurance brokers.

Additional insight from the American Association of Retired People (AARP) cited common patient refrains that include:

Prescription drug needs have changed, or costs have increased.

Patient is spending extended periods of time in a different state or geographic region.

Patient has been diagnosed with a chronic condition that has triggered a change in coverage needs. As an example, AARP cites a patient diagnosed with diabetes who desires a Medicare Advantage plan that includes coverage for a gym membership or diabetes-specific programs.

Preference for a specific doctor.

Regardless of the reason, patients will find many options from which to choose. So many in fact, that the process can be quite confusing. Patients may have difficulty drilling into each plan to identify specific benefits, or drug formularies. Or, a patient may have trouble conducting side-by-side comparisons of plans. For help, many beneficiaries will turn to their local pharmacist – the healthcare provider they see the most. Responding to these inquiries provides an excellent opportunity for pharmacists to strengthen relationships with Medicare patients and solidify their role as a valued healthcare professional.

What Steps Should Pharmacies Take to Prepare for Open Enrollment?

Pharmacists can ensure they are well-prepared to counsel patients by keeping informed about 2026 Medicare program changes, and plan availability. Especially relevant developments include:

Fewer Medicare Drug Plans. Patients will see a decrease in the number of stand-alone Medicare Part D drug-benefit plans available for 2026. According to Avalere Health, 2026 offerings will include 360 plans, which is down from 464 currently offered and 709 available during 2024. Patients should carefully review existing coverage to ensure their medications will be included in their plan going forward. Or, if their plan has been discontinued, care must be taken to select a new option with adequate coverage.

Increased out-of-pocket costs. According to Medicare.gov, out-of-pocket costs for prescription drugs will be capped at $2,100 during 2026. This marks a $100 increase from current levels. However, the cap only applies to medications that are covered by a patient’s plan, which means it’s very important for patients to ensure their prescribed drugs are covered.

Many Plans are Changing in 2026. In late September, CMS released the 2026 premiums, deductibles and other key information for Medicare Advantage and Part D prescription drug plans. The average premium for Medicare Advantage plans will be lower in 2026, at $14 per month, compared to $16.40 during 2025. The average 2026 premium for stand-alone Part D drug coverage will be $34.50 per month, a decrease from the 2025 average of $38.31 per month.

Medicare Advantage Benefits may be Changing. CMS notes that Medicare Advantage benefit options “will remain stable” during 2025, including supplemental offerings for hearing, dental, and vision. However, reporting by the Wall Street Journal notes that several plans are scaling back benefits that had been offered as a way to attract enrollees. The article notes certain plans are eliminating benefits including gym memberships, fitness trackers, home repairs, and healthy foods.

Beneficiaries who have come to rely on certain benefits will need to determine if coverage will still be available, and if they are not, evaluate whether a different plan could better meet their needs.

GLP-1 Drugs are Approved for Obesity, but Not Yet Available. GLP-1 medications have been very much in the news, with President Donald Trump announcing agreements with Eli Lilly and Novo Nordisk to reduce prices for Ozempic, Wegovy and Zepbound. The National Community Pharmacists Association (NCPA) issued a statement clarifying the availability and cost of these medications for Medicare patients. “These reductions in price will enable Medicare and Medicaid coverage of obesity drugs,” the NCPA statement explained. “The Medicare prices of Ozempic, Wegovy, Mounjaro, and Zepbound will be $245.”

NCPA notes that Medicare will cover Wegovy and Zepbound for patients with obesity and related comorbidities for the first time, with Medicare beneficiaries responsible for a copay of $50 per month. However, these drugs will likely not be available to beneficiaries in the near future, at least not on a widescale basis.

“NCPA is working with the [Trump] administration to ensure that any GLP-1s covered by Medicare or Medicaid will be available in community pharmacies and that pharmacies will be reimbursed fairly for dispending the drugs. This will likely occur through a pilot program that is still in the works.”

In addition to keeping informed about plan and program changes, pharmacists can best-serve patients with steps that include:

Review and update patient data. Pharmacists should review all Medicare patient records to ensure that contact info, insurance details and Medicare ID numbers are accurate.

Proactively reach out to Medicare Advantage and Part D plan beneficiaries. Research by eHealth found that 36% of Medicare Advantage and Part D plan enrollees said they were unaware that “significant cost and benefit changes are expected for 2026.” Pharmacists can help these patients ensure they are receiving optimal coverage by reminding them that Open Enrollment offers an opportunity to make a change, and encouraging them to explore their options.

Staff Training. Ensure that all staff members are updated about pending Medicare changes, and able to direct patients to appropriate resources.

PrimeRx Supports Pharmacies – and Patients – During Medicare Open Enrollment

Pharmacists can take advantage of technology-based tools to help steer patients through the Open Enrollment period. This includes the PrimeRx pharmacy management system, which automates key pharmacy workflows, while also offering direct integration with third-party solutions that address specific plan coverage and formulary issues. Pharmacists can rely on PrimeRx for key functionality that includes:

Patient Records Management. PrimeRx allows pharmacists to create and maintain comprehensive patient health records. The system maintains a history of each patient’s prescription medications along with information about a patient’s medical history including diagnosed conditions, lifestyle behaviors, family situation, living situation, and any other information that would add to an understanding of a patient’s profile. Having access to this detailed information allows better insight into a patient’s coverage needs and will help guide a discussion about plan options. Once a patient decides to make a plan change, PrimeRx seamlessly updates the patient’s record, and makes all necessary adjustments.

Patient Communication. Good communication helps ensure patients are aware of the Open Enrollment period, and know where to turn for information and counsel. PrimeRx offers extensive communication capabilities that keep patients informed through targeted SMS text and email messages. Pharmacists can quickly identify all Medicare Advantage, Part D, and Traditional Medicare patients and proactively reach out to them with a reminder about the importance of reviewing current plan coverage. The system also enables two-way communication, which allows pharmacists and patients to interact about drug coverage and other plan-related issues.

Medicare Plan Comparisons. PrimeRx offers direct integration with Enliven Health, which allows pharmacists to quickly and seamlessly conduct plan comparisons. Pharmacies can rely on the Enliven Health “Match” solution for capabilities that include:

Market leader. Match is the market-leading, CMS-approved comparison platform.

Informed decision-making. Patients have full visibility into plan options, including comparisons of out-of-pocket costs.

Identification of affordable drug alternatives. A Formulary Lookup tool suggests affordable drug alternatives covered by patients’ plans.

Patient-facing “plan finder” for at-home use. Match includes NavigateMyCare which allows patients to compare and enroll in plans from the convenience of their homes.

Retain patients, increase loyalty, and gain business. Pharmacies can generate goodwill by offering plan comparisons to existing and prospective patients. Patients are 30 percent more likely to stay with, or join, a pharmacy that performs a plan comparison for them.

Mitigate Administrative Fees and Reimbursements. The solution provides real-time comparisons of each plan’s administrative fees and reimbursement rates, allowing greater insight into patient options.

Prescription Benefit Review. PrimeRx also includes direct integration with the Real-Time Prescription Benefit from Surescripts solution. The solution provides real-time information about a patient’s covered medications. This in turn allows the pharmacist to determine if a prescribed medication is covered, and the patient’s copayment. Having ready access to this information can help determine if a plan covers a patient’s list of prescribed medications, or if a change in plans may be warranted.

Business Records – Report Generation. PrimeRx helps pharmacy owners track the plans their patients use, along with the impact each plan has on the pharmacy’s bottom line. Pharmacy owners can use this information as guidance in determining prescribers affiliated with a certain plan, covered medications, reimbursement rates, and patient satisfaction with the plan’s performance.

Audit compliance. The PrimeRx system’s extensive recordkeeping capabilities are especially helpful in responding to audit inquiries. Pharmacies can have immediate access to requested records including copies of prescriptions, proof of payment, patient signatures, and dispensing records, among many other requested items. Pharmacy staffs no longer must waste precious time combing through boxes looking for this information. Instead, all records are seamlessly stored within PrimeRx, and available with just a few keystrokes.

Open Enrollment provides an annual opportunity for Medicare patients to recalibrate their coverage selections to ensure optimal coverage for their medical and prescription drug needs. But the process is only effective if patients know about it, and understand how to take advantage. Pharmacists have an important role in the process, and technology-based tools such as PrimeRx make it easier to fulfill that role and better serve patients.