Webinar Summary: Beyond Open Enrollment: Exploring Medicare Plan Comparison Opportunities After AEP

The Annual Enrollment Period (AEP) may be the busiest time of year for Medicare-focused pharmacies, but it's far from the only opportunity to help patients and strengthen your business. In “Beyond Open Enrollment: Exploring Medicare Plan Comparison Opportunities After AEP,” EnlivenHealth’s Marvin Guardado shared critical insights about the evolving Medicare landscape and how pharmacies can maintain momentum well beyond December 7th.

The 2026 Medicare Landscape: What's Changed

The Medicare market is undergoing significant transformation as carriers reshape their strategies in response to financial pressures. Rather than simply consolidating, major insurers are making deliberate choices about where to compete and how to protect their margins.

Carrier Strategies Diverge

Different carriers are taking distinctly different approaches:

Humana stands out as the most aggressive player, betting on both scale and specialization simultaneously. The company added 48 Medicare Advantage plans (a 10% increase) and led the market with 41 new Special Needs Plans. They now operate over 500 Medicare Advantage plans and more than 200 Special Needs Plans.

CVS and Centene are pivoting toward specialized populations. CVS eliminated 70 Medicare Advantage plans but added 30 Special Needs Plans, while Centene reduced 37 Medicare Advantage plans and added 14 Special Needs Plans. Both are leveraging their integrated assets—pharmacies, PBMs, and clinics—to serve targeted patient populations rather than pursuing broad market share.

UnitedHealth and Elevance (formerly Anthem) are prioritizing profitability over expansion. UnitedHealth trimmed 61 Medicare Advantage plans while adding just seven Special Needs Plans, and Elevance reduced 35 plans, added three Special Needs Plans, and exited the PDP market entirely.

Impact on Patients and Pharmacies

These strategic shifts have real consequences: approximately 2.6 million patients will lose their current coverage in 2026. With roughly 3,000 counties nationwide, that averages about 800 affected patients per county—though some areas face much larger disruptions. Nassau County, New York, for example, will see 12,000 patients lose coverage.

For pharmacies, this creates both challenges and opportunities. Patients need guidance navigating these changes, and pharmacies are positioned to help them find plans that ensure continuous coverage, include their medications, and provide fair reimbursement.

The PDP Market: A Challenging Landscape

The standalone Prescription Drug Plan market faces even more severe contraction. In many counties, only two truly affordable PDP options remain under $30 monthly—typically WellCare and Humana plans. Many other options exceed $50 or even $100 per month.

As patients become more cost-conscious, many gravitate toward lower-premium plans without considering the full picture. However, these budget options often carry aggressive reimbursement rates that can significantly impact pharmacy margins. For instance, WellCare and HealthSpring plans may reimburse at AWP minus 24% on brands.

This dynamic makes Medicare Advantage plans increasingly attractive alternatives. Many MA plans offer $0 premiums while providing better pharmacy reimbursement rates and additional patient benefits. Rather than having just a couple of affordable PDP options, pharmacies can often identify a dozen or more Medicare Advantage plans that serve patients well while supporting pharmacy sustainability.

Finishing AEP Strong: Strategic Priorities

With the final weeks of AEP remaining, pharmacies should focus their outreach strategically:

Target poorly reimbursing plans first. Identify patients on plans with aggressive reimbursement rates and invite them in for quick comparisons. Help them find alternatives that save money while improving your margins.

Consider medical billing opportunities. For pharmacies credentialed to bill medical benefits, plan selection directly impacts clinical billing opportunities for services like medication synchronization and OTC consultations in 2026.

Focus on LTC at home patients. If you offer long-term care at home services, review your patient list to identify those on plans that don't recognize this model. Optum and Express Scripts are the two major PBMs supporting LTC at home, creating revenue opportunities that might justify steering patients toward these networks.

Engage dual eligible populations. About one in five Medicare patients also has Medicaid. Dual Special Needs Plans offer $0 premiums, richer benefits, and OTC card stipends that can generate front-end revenue untouched by PBM pressures.

Medicare Enrollment Opportunities Beyond AEP

December 7th isn't the end of Medicare enrollment—it's more of a holiday break. Multiple enrollment windows throughout the year allow pharmacies to maintain patient engagement and continue helping people optimize their coverage.

Medicare Advantage Open Enrollment Period (January 1 - March 31)

This quarter-long window allows patients already enrolled in Medicare Advantage plans to make one-time switches to different MA plans or back to Original Medicare. It's a critical opportunity to help patients who selected the wrong plan during AEP, took no action despite their plan terminating, or discovered formulary changes and increased costs when filling prescriptions in January.

More than half of Medicare beneficiaries are on Advantage plans, making this an extended enrollment period for a majority of your Medicare patients. Many experienced brokers report that this first-quarter period has become just as important as AEP itself.

Initial Enrollment Period

When patients turn 65, they have a seven-month window (three months before their birthday, the birthday month, and three months after) to select coverage for the first time. This is one of the most competitive times in the market, with brokers and carriers actively reaching out to these newly eligible patients.

If pharmacies aren't part of this conversation, retention issues can arise. Patients might enroll in plans where you're not in-network or choose plans with poor reimbursement rates. Automated campaigns can help ensure you reach these patients as they approach their 65th birthday, positioning your pharmacy as a trusted resource.

Special Enrollment Periods

Triggered by qualifying life events—losing coverage, moving, losing Medicaid eligibility, or experiencing natural disasters—Special Enrollment Periods create year-round opportunities to help patients in vulnerable situations who need trusted guidance.

Dual Eligible and Extra Help Patients

These dynamic patients can make coverage changes monthly, providing continuous opportunities to optimize their plans. They don't need to wait until next year's AEP to adjust coverage, making them particularly responsive to ongoing education and support.

Building Effective Outreach Systems

Awareness is critical. Many patients don't realize that AEP isn't the only time to make coverage changes. Effective communication requires multiple touchpoints:

Word-of-mouth remains powerful. When you help patients find plans that save money and cover their medications, they'll tell friends and family about your assistance.

Automated text and phone campaigns can proactively reach dual eligible patients, those on Medicare Advantage plans in the first quarter, and anyone approaching their 65th birthday with reminders about reviewing options.

In-store and digital presence matters too. Strategic signage near registers and consultation areas, bag inserts with prescriptions, updated IVR greetings, and website banners all reinforce that Medicare plan reviews are available year-round.

Extending Your Reach with Navigate My Care

For patients who trust your pharmacy but prefer handling things independently or have mobility challenges, EnlivenHealth's Navigate My Care patient portal provides a convenient solution. Pharmacies can send patients secure links to review plan options prepared specifically for them.

When patients log into Navigate My Care, they see all drugs they're filling at your pharmacy without manual data entry, a list of in-network plans, and comparison tools. They can explore options, enroll, or connect with broker partners at any point. The portal now includes a built-in penalty calculator that predicts potential late enrollment penalties, helping patients make informed decisions and avoid unnecessary costs.

Key Takeaways

The Medicare landscape continues evolving, but one constant remains: patients need trusted guidance navigating their options. While AEP represents the busiest enrollment period, numerous opportunities exist throughout the year to help patients optimize coverage while supporting your pharmacy's financial health.

By understanding carrier strategies, targeting outreach strategically, and maintaining engagement through multiple enrollment periods, pharmacies can strengthen patient relationships, protect margins, and position themselves at the center of care year-round.

The goal isn't just surviving AEP—it's building sustainable systems that serve patients and your business throughout every season.

To watch the webinar on demand, click here!

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For more information about the EnlivenHealth Match solution, visit enlivenhealth.co.

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