Your Dual Eligible Report identifies dual eligible patients at your pharmacy that have a potential win-win opportunity to enroll in a new plan that's better for the patient and the pharmacy. Dual eligible patients have special enrollments periods so you can benefit from helping these patients all year round.

Dual eligible patients can only change their plan outside of Open Enrollment once every 3 months from January through September. 

Win-Win Opportunities

Dual eligible patients have fixed copays, so as long as the plan is a benchmark plan, costs for the patient are quite similar across the board. This means there's a lot of flexibility in helping them find a plan that:

  • increases your pharmacy's reimbursements AND 
  • saves the patient money or costs the same but is beneficial in other ways (i.e. higher CMS star rating, all drugs covered on the formulary) 

Working with these patients outside of Open Enrollment allows you to take effective action when your pharmacy experiences underwater claims. If, in the middle of the year, you notice significant losses with Plan X, you can use your Dual Eligible report to identify patients on Plan X that potentially have a better plan option to enroll in.

To get started:

On the left, go to Opportunities and click Dual Eligible in the Worklist dropdown box:

Remember, these are your potential win-win Dual Eligible opportunities, not a comprehensive list of your dual eligible patients. 

  1. Depending on the number of opportunities that need to be reviewed, consider filtering by Total Rx Billings or searching by plan BIN to further segment the list and focus on your high-value patients.
  2. Click each opportunity to see an overview of what their estimated out-of-pocket cost and annual full cost (revenue) would be if they're enrolled in the cheapest plan option. 
  3. Click "compare plans" to review the details of each plan option and determine if it's an opportunity worth pursuing.

Find the low hanging fruit

Finding the "right" opportunities to pursue requires some effort. You want to prioritize the low hanging fruit, the opportunities that will be easy to capitalize on. Taking the time to find these valuable opportunities and successfully take action on just a few can pay-off significantly. These are the factors you should look for:

Patient's current plan is detected (or can easily be determined)

Amplicare isn't able to confidently detect the current plan for all of your patients. You need to confirm the current plan before helping them enroll in a new plan. So, focus on the Dual Eligible patients that have detected current plans! If there's a detected current plan there will be a "Current Plan" displayed right at the top of the plans list:

Current plan is a PDP (Prescription Drug Plan)

Medicare Advantage plan comparisons are more complex than stand-alone PDP comparisons because the patient's health benefits must be taken into account. Focus on patients who are currently enrolled in PDP's so that the plan comparison is much more straightforward and easy (remember, low hanging fruit!):

There's an alternative plan that's beneficial for the patient

Confirm if there's an alternative plan that has at least one of the following attributes:

  • cheaper total out-of-pocket (OOP) cost
  • the same OOP cost with a higher CMS star rating (higher star rating = plan will provide better service to the patient)
  • the same cost with fewer drug restrictions

Here's an example of an alternative plan with a cheaper OOP cost: 

All medications are covered

To go after low hanging fruit, address opportunities in which the cheapest plan for the patient does not have any not covered ("NC") drugs listed. Often times dual eligible patients will receive formulary exceptions (essentially a Prior Authorization) for medications that are not on their current plan's formulary or in some states Medicaid pays for most drugs not covered by Medicare.  If this is the case in your situation, feel free to disregard this factor.

Initiate an outreach campaign each quarter

After you identify a low hanging fruit opportunity, the next step is to reach out to the patient and have a plan consultation with them. Sometimes, this can be the biggest obstacle, but don't let it stop you! Make it a focus at the beginning of each quarter to personally engage with your dual eligible patients via phone or in-person when they come by to pick up their medications. Explain that you can help them save some money on their medications and they have a special period of time to review their options and enroll in a new plan.

Print a handout for the patient in the Dual Eligible report to help start the conversation!   

What's Next?

Looking to improve you consultations with patients? Check this article out!

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