The Dual Eligible report explained

Your Dual Eligible report identifies needle-in-the-haystack opportunities for your dual eligible patients, who can change their Medicare plan once each quarter of the year. Opportunities are generated if, based on our analysis, a dual eligible patient has an alternative plan option that could be more beneficial for them in one of two different ways:

  1. cheaper total out-of-pocket (OOP) cost compared to their current plan

  2. the same OOP cost with a higher CMS star rating (higher star rating = plan will provide better service to the patient)

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)

Recommended Plan Alternative

For every opportunity now run an analysis and recommend an alternative plan for the patient based on several factors including out-of-pocket cost, estimated revenue, DIR fees, CMS star rating, and drug restrictions. Basically, we do the work for you!

When you click an opportunity you'll see an overview of these factors for the patient's Current Plan and Recommended Plan, so you can do a quick comparison and decide whether you want to continue pursuing the opportunity:

Note: if there is an alternative plan option that doesn’t have DIR fees at all, we will always prioritize recommending that plan over others!

Identify your highest priority patients

Recommended Filters

Use "Recommended Filters" to further pinpoint your highest priority patients to engage with. Top Opportunities (“WIN-WINs”) will identify patients that have an alternative plan option that has a higher projected revenue for the pharmacy, taking into account estimated DIR fees.

To access these WIN-WIN opportunities:

  1. Click your Opportunities tab on the left

  2. Select Dual Eligible from the worklist dropdown

  3. Select the Recommended Filter dropdown and choose Top Opportunities (WIN-WINS)

Find the low hanging fruit

To even further filter your opportunities, find ones that will require less effort on your end by consider the following:

Current plan type

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 (low hanging fruit!).

You can do this by adding an "Advanced Filter": Medicare Plan Type = PDP

Plan restrictions

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. Oftentimes 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 drugs not covered by Medicare. However, the process for obtaining formulary exceptions requires additional work and potential gaps in coverage, so it's better to prioritize patients that don't have a lot of these restrictions.

Steps for taking action

Once you have your opportunities filtered appropriately, follow these steps to take action on an opportunity:

STEP 1: Click an opportunity to see an overview of the patient's current plan vs. recommended plan.

STEP 2: Click COMPARE PLANS to review the details of all alternative plan options in the patient's profile.

STEP 3: You will be redirected to the patient's full list of plans, where the patient's current plan and recommended plan will already be selected in the list! Select any additional plans you want to review with the patient and then click SAVE COMPARISON.

STEP 4: Call the patient and have them access their patient portal ("Navigate") by following the instructions provided above the drug list (clicking the "Read More" link).

When the patient logs in to their portal they will be automatically directed to the comparison you just saved, so you can seamlessly consult with them over the phone and help them enroll in a new plan

Additional tips for success

  • It's imperative that during the consultation process you verify with the patient what their subsidy and current plan are. Learn more.

  • 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 from their Dual Eligible opportunity to help start the conversation!  

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