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Latest news and updates about the Medicare and pharmacy industries.

Medicare Plan Formularies Are Changing. Here’s How to Help Your Patients

Posted on March 12, 2021 by Amplicare Team

It has now been over a year since COVID-19 landed on our shores and fundamentally changed all of our lives. From the quarantining to the isolation to the complete 180 of how we all used to live, it has been at best disorienting and at worst devastating. 

As we look forward with optimism now that so many vaccines are available, it’s essential to remember that patients still have important questions about their care beyond COVID-19.

According to GoHealth’s “Biannual Medicare 2020 Report,” which surveyed more than 2,100 Medicare beneficiaries and those nearing eligibility: 

  • 57% of those nearing eligibility are confused about finding a plan that’s right for them
  • 47% of the same group admit they don’t know where to start

These statistics show that patients are looking for guidance when it comes to their Medicare plans and need a pharmacist who will listen to them. This provides a chance for you to become a dependable resource that your patients can always count on.  

One clear way to help Medicare patients is by providing guidance on their prescription medications and insight into how their plan changes may affect their coverage.

Why Pharmacies Need a Formulary Lookup Tool

As a pharmacist, you know that plans change formularies each year. And you know that changes to coverage can cause delays at your pharmacy and confusion to your patients. 

Having a lookup tool to help you keep track of any changes ensures your pharmacy stays on top of key formulary restrictions, such as: 

  • Prior Authorizations: If a drug has prior authorization, you will need to work with the plan, the doctor, and the insurance company to get an exception about specific prior authorization requirements. 
  • Quality Limits: If a drug has a quantity limit restriction, plans may limit the quantity of drugs that they cover over a certain period of time, and you will need to work with the plan for authorization to fill a higher quantity.
  • Step Therapy: If a drug has step therapy restrictions, patients will need to try one drug to treat their medical condition before getting covered for a second drug for that condition. You'll need to work with the plan and the patient’s doctor to get an exception.
  • Not Covered: If a patient’s medication isn’t covered on a plan’s formulary, the enrollee receives no coverage benefits for that medication. Since the medications are not covered, they don’t count toward Coverage Phase thresholds.

Any one of these restrictions can lead to delays in care/therapy, so having a proactive formulary lookup tool can help you communicate more easily with patients about their options, and showcase a deeper level of care for their long-term well-being. 

Using the Formulary Lookup Tool

Using this simple to use and easy-to-understand platform, Amplicare makes it easy to get the answers your patients care about most—their health.

With the Formulary Lookup tool, you can easily:

  1. Discover if a patient’s plan covers a specific drug.
  2. Determine how much a medication costs at your pharmacy.
  3. Educate patients on plan restrictions for different medications.
  4. Find more cost-effective alternatives for a medication.
  5. Find out which plans have what restrictions.

This is your ultimate tool to help determine if your patients are paying too much for a medication, find out what their copay might be for any given medication, and help you create a stronger patient-pharmacist relationship.

Providing Year-Round Care 

For many patients, the Annual Enrollment Period (AEP) is their only time to make changes to their Medicare plans. Once the AEP is over, you still have a few opportunities to help patients either switch plans, sign up for new plans, or just give them the tools they need to understand all their plan options.

Amplicare’s platform can help you identify patients looking to switch plans outside of the traditional AEP, including Dual Eligible patients who are enrolled in both Medicare and Medicaid. Because they can switch plans each quarter, they are constantly looking for the right care and a pharmacist who understands their needs. With over 12 million Dual Eligible patients in the U.S., that means there are plenty of opportunities for your pharmacy to provide that enhanced level of care. 

Why is this good news for your pharmacy? 

Patients are 30% more likely to stay with a pharmacy that performs a plan comparison for them, and working with these patients all year means more chances to help them find a plan with better coverage or fewer restrictions. 

Your pharmacy also benefits from visibility into mutually beneficial opportunities that help patients save money and reduce DIR fees or increase profits (read more about lowering DIR fees here).

By proactively reaching out to patients about their options, you’ll demonstrate your commitment to patient’s long-term well-being and increase the likelihood that they’ll become lifelong customers.

Staying Connected to Patients

Even with a large vaccine roll out, it’s still critical that we remain socially distanced. But that doesn’t mean we have to become less engaged.

With Amplicare Navigate, your patients have a safe digital environment to compare plans from the comfort of their own homes and:

  • Review plans in-network with your pharmacy
  • Gain access to plan comparisons initiated in the pharmacy
  • Confidently choose a plan that works for them

Plus, with a CMS-approved resource center at their fingertips, your patients will have all they need to make an informed decision about their options.

Our Formulary Lookup tool is just one example of the complete suite of services that Amplicare provides. To learn more about our Formulary Lookup tool or any of our other solutions designed to optimize your pharmacy performance, click on the link below.

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