How pharmacists can help patients through Medicare Open Enrollment

In this article:

• The pharmacist's role
• What to say and what not to say
• Patient reminders
• Choosing plans
• Timing tips
• How to help when Medicare won't cover an Rx
• FAQs

In this article

• The pharmacist's role
• What to say and what not to say
• Patient reminders
• Choosing plans
• Timing tips
• How to help when Medicare won't cover an Rx
• FAQs

For around six weeks each fall, pharmacists see a rise in questions about Medicare coverage. October 15 to December 7 is the Medicare Open Enrollment Period. During this time, plans often make changes to premiums, copays, formularies, and pharmacy networks that go into effect January 1. Yet one analysis of Medicare Current Beneficiary Survey data found that almost 70% of beneficiaries don’t check their coverage changes or compare options. By the time January comes around, patients may be confused about why their copay tripled or their medication is no longer covered.

Why pharmacists become the go-to during Open Enrollment

Most patients stop by the pharmacy more often than their doctor’s office, whether it’s to pick up prescription medications, over-the-counter drugs, or other basic health supplies. They also have easy access to a pharmacy team member who has their medication history and insurance information at the click of a button.

For many pharmacists, building strong relationships with patients is a key part of their work. A 2026 survey found that 93% of adults have a preferred pharmacy and more than half had spoken with a pharmacist about a medication in the past year. The pharmacy counter is a convenient place to ask questions, especially when it comes to insurance.

What pharmacists can (and can’t) say about Medicare plans

The Centers for Medicare & Medicaid Services (CMS) has strict anti-steering and anti-kickback rules when discussing Medicare plans with patients. In general, you can explain how benefits work, help clarify any Medicare terms, and hand out CMS support materials. You can also direct patients to get more information from Medicare.gov or a State Health Insurance Assistance Program (SHIP) counselor.

What pharmacists and other healthcare professionals can’t do is steer patients toward a specific plan. In other words, the pharmacy counter is not where patients should be enrolling in Medicare plans.

Consider using the following language when talking about Medicare coverage.

• “Your plan moved this drug to a higher tier next year. The Medicare Plan Finder will show what each one charges for your medication.” instead of “That plan is better for you.”
• “The right plan depends on your drugs and your pharmacy. A SHIP counselor can help compare them for free.” instead of “Everyone’s switching to that plan.”

Red flags to mention in a patient’s plan renewal

Plans mail an Annual Notice of Change each September with information about upcoming changes in January. However, many patients never get around to reading it. Here are some potential things to remind patients about:

• Formulary changes: Check whether a medication is in a different tier, requires prior authorization or step therapy, or is no longer covered at all. You might have to explain that a formulary is their covered drug list, and that their medication may need prior authorization, which needs to be handled by their healthcare provider.
• Preferred network changes: A patient’s preferred pharmacy might fall out of network due to changes in their current plan. Not using a preferred pharmacy can mean higher copays.
• Premium versus total cost: For 2027, no Part D plan can set a deductible above $700, and out-of-pocket spending is capped at $2,400. A low premium plus a full deductible could cost more over a year than a higher-premium plan with no deductible.
• Coverage phase: With the coverage gap, or “donut hole,” gone, patients move from paying their deductible to entering the initial coverage stage where they pay up to 25% of a drug’s cost, and then to catastrophic coverage, where they pay nothing. Patients on a specialty drug may hit that cap early, which could affect which plan might be best for them. In addition, patients can spread their out-of-pocket costs over monthly payments with the Medicare Prescription Payment Plan.

How to handle the ‘which plan should I pick’ question

As long as you’re not officially endorsing or recommending a specific plan, you can help guide patients on what factors to keep in mind when picking a plan. You don’t want to brush the patient off since that could lose the patient’s trust easily.

Instead, you can redirect the patient by saying something like, “I can’t recommend a specific plan, but what I can do is print your refill history. You can discuss your prescriptions with a SHIP counselor who can help you compare plans for free.”

SHIP provides free Medicare counseling at shiphelp.org or 877-839-2675. Medicare’s Plan Finder at medicare.gov estimates annual costs for all plans and will list potential restrictions like step therapy, quantity limits, or prior approval. Also, 1-800-MEDICARE is open 24 hours a day for anyone who would rather talk to a person.

Timing tips that make January smoother

Coverage starts on January 1 as long as patients request their desired changes by December 7. Patients who wait until the final days of the Open Enrollment Period might come to the pharmacy in January without an ID card or a member number the pharmacy can bill. That’s why you might want to remind patients to do what they need to do before mid-November.

Although older patients might miss the deadline, they still have options. Anyone already in a Medicare Advantage plan gets a second window from January 1 to March 31. The changes are effective the first of the month after the plan gets the request. When a new plan doesn’t cover a drug a patient already takes, Part D sponsors must provide a temporary supply of at least a month within the first 90 days of coverage, which should give plenty of time for an exception request. People enrolled in Part D Extra Help (the Low-Income Subsidy) may have additional opportunities to switch plans, as well.

When a new plan doesn’t cover what a patient needs

In many cases, a patient may run into obstacles with coverage. Their medication may have moved tiers, their deductible hasn’t been met, or the medication isn’t on the formulary at all.

For these patients, a prescription discount card can be a helpful alternative to running the claim through Part D and navigating the prior approval process, or filing an appeal. A SingleCare coupon can be used instead of a Part D plan, with the prices for some medications sometimes being lower than a plan copay. However, patients should know that SingleCare and Medicare Part D benefits can’t be combined, and cash payments with a discount card don’t count toward the $2,400 cap or their deductible. A prescription discount card can make the greatest impact during the deductible phase, for a non-formulary drug, or when an appeal is pending.

Bottom line

Pharmacists don’t need to be experts in all of the Medicare plans available. In fact, they shouldn’t be steering patients to any specific plans. However, they can be helpful for informing patients on different factors to keep in mind while comparing plans, such as their formulary, preferred pharmacy, and the annual out-of-pocket spending cap. Pharmacists can also guide patients to the right resources for help comparing plans.

Frequently asked questions

Can a pharmacist tell a patient which Medicare plan to choose?

No, pharmacists can’t steer patients toward a specific plan. Instead, they can explain benefits, point out any changes, and refer patients to resources that can help them choose.

What is the Medicare donut hole, and does it still apply?

The Medicare coverage gap, also known as the donut hole, was done away with at the start of 2025. With the Inflation Reduction Act, a hard annual cap on out-of-pocket costs for covered Part D drugs replaced the donut hole. The cap is set at $2,400 in 2027, and when a patient hits this cap, they pay nothing more for covered drugs that year.

Can patients switch pharmacies if their new plan has a preferred network?

Patients can fill their prescriptions at any pharmacy in their plan’s network. A preferred pharmacy in the network generally has lower copays than a standard one.

What happens if a patient enrolls in a new plan late in the month?

Coverage starts January 1 either way, but the patient’s plan information may not appear in the system if they submitted an enrollment close to December 7. Making a decision by mid-November can help prevent any delays in filling their prescription in January.

Where can pharmacists send patients for unbiased plan comparisons?

SHIP counselors and Medicare’s Plan Finder at medicare.gov are the go-to resources for free and unbiased comparisons. Pharmacists may want to remind patients to have their full medication list handy while comparing plans.