Webinar Summary: The Hidden Profit Centers of Medicare Advantage: A Community Pharmacy Primer

As Annual Enrollment Period kicks off, independent pharmacies face a critical question: How do we turn Medicare plan comparisons from a retention tool into a revenue growth engine?

On October 14th, 2025, EnlivenHealth hosted a webinar titled “The Hidden Profit Centers of Medicare Advantage: A Community Pharmacy Primer.” Speakers included EnlivenHealth’s Marvin Guardado alongside pharmacist and pharmacy owner Traci Bayer, PharmD, who revealed how her rural Texas pharmacy has transformed Medicare Advantage plans into multiple profit centers—while strengthening patient relationships and community trust.

The 2026 Medicare Landscape: Why Advantage Plans Matter More Than Ever

The Medicare market is undergoing dramatic consolidation. For 2026, standalone Part D plans (PDPs) have been cut nearly in half—from roughly 20 options per beneficiary to closer to 10. Meanwhile, carriers are raising premiums on richer PDP plans while slashing prices on bare-bones options.

The WellCare Dominance

Centene's WellCare plans now control 43% of the PDP market, largely due to $0 premium offerings in most states. But there's a catch: these plans roll up to the Express Scripts Medicare network, which reimburses brand medications at approximately AWP minus 24%—rates that leave most independent pharmacies operating at a loss.

In contrast, approximately 75% of Medicare Advantage plans offer $0 premiums on prescription coverage. This gives patients the affordability they're seeking while opening access to plans that reimburse pharmacies more fairly. Currently, 50-60% of Medicare beneficiaries are enrolled in MA plans, with projections climbing to 64% within the next decade.

What Makes Medicare Advantage Different

Beyond prescription coverage, MA plans offer a critical advantage that original Medicare doesn't: an annual out-of-pocket maximum. Once patients hit this limit (averaging around $5,500), they pay nothing more for covered services for the rest of the year.

Compare this to original Medicare, which requires patients to pay 20% of covered costs indefinitely with no cap. For seniors facing hospital stays or major procedures, this financial protection is invaluable. Part D drug coverage does come with an out-of-pocket maximum, however.

Profit Center #1: Medical Billing for Clinical Services

Perhaps the most significant opportunity lies in billing clinical services to the medical benefit. Traci Bayer's Hillcrest Pharmacy has built a robust clinical services program that includes:

Vaccine Consults

Pharmacies can bill for the time spent reviewing vaccine administration records and counseling patients using evaluation and management codes. "Medicare Advantage plans do pay for vaccine consults in our area," Traci explained. "We're billing for the time reviewing clinically their vaccine screening, not just giving the shot."

This creates a consultation fee on top of the vaccine administration fee—turning a single patient interaction into multiple revenue streams.

Med Sync Consultations

Some pharmacies are billing Med Sync consults to Medicare Advantage plans using CPT code 99212, earning approximately $30 per consult monthly. "It's subscription-like revenue that can turn a patient who was previously unprofitable into a profitable one," Marvin noted.

The Humana Performance Bonus Connection

For pharmacies contracted with Humana, there's an added benefit: Humana's adherence-based performance bonus program applies only to their MA plans. By aligning more patients with Humana MA plans and providing Med Sync services, pharmacies can simultaneously:

• Earn monthly consultation fees
• Improve adherence rates
• Maximize year-end performance bonuses

The Credentialing Requirement

To bill medical services, pharmacies must be credentialed and contracted with carriers as providers. Organizations like CPESN and Provider CSAO can help navigate this process, though it requires upfront investment in time and resources.

"It takes about six months to a year of doing it and just trying it," Traci advised. "Trying to provide the service, billing the code—it takes credentialing and partnering with someone to send your codes and make your notes."

Profit Center #2: OTC Benefit Cards

Many Medicare Advantage plans, especially dual special needs plans, offer over-the-counter benefit cards that patients can use like debit cards at participating pharmacies.

How OTC Cards Work

These cards are processed through separate vendors:

• Incom/OTC Network: Processes for Humana and Aetna plans
• S3 (United’s division): Handles UnitedHealthcare plans
• Nation Benefits and ProHealth: Cover various regional plans

The Setup Process

Unlike PDP claims that run through your pharmacy management system, OTC cards require:

• Separate device/card reader from the OTC processor
• Dedicated portal for transactions
• Direct contracts with individual processors

"It does take a little extra effort," Traci acknowledged. "It's a separate reader and a whole separate portal. It's not processed through your credit card processor."

The Revenue Opportunity

For pharmacies with nutrient depletion programs or supplement sales, OTC cards create a payment mechanism for products patients might otherwise decline due to cost. Some pharmacies are even billing OTC consultation fees (CPT 99401) for 15-minute conversations about supplement selection—earning an additional $30 per consult.

Profit Center #3: Long-Term Care at Home

For pharmacies offering compliance packaging and medication synchronization, long-term care at home (LTCH) represents significant enhanced reimbursement opportunities.

Who Recognizes LTCH

Currently, two major PBMs recognize medical at home as long-term care:

• Express Scripts (WellCare plans)
• Optum (AARP Part D plans and UnitedHealthcare MA plans)

"We can bill at enhanced reimbursement plus a dispensing fee for both of those PBMs," Traci explained. "That is a big thing for us, looking at: Does this patient fit the medical at home requirements? Do they get their meds packaged? Do they need help with their meds?"

The Strategic Nuance

This creates an important exception to the "avoid WellCare" guidance: If a patient qualifies for LTCH services and your pharmacy is set up to provide them, WellCare plans become viable—even desirable—because of the enhanced reimbursement rates for packaged medications.

Real-World Results from Rural Texas

Traci Bayer's Hillcrest Pharmacy in Vernon, Texas (population 10,000) demonstrates what's possible when Medicare plan comparisons become integrated into comprehensive patient care.

Her Approach

• Monthly senior center classes: Blood pressure screenings, A1C testing, cholesterol checks, and medication education
• Proactive outreach: Maintains ongoing spreadsheets of patients struggling with co-pays or medications
• Year-round service: Uses the Opportunities section in EnlivenHealth Match to identify patients turning 65 or dual-eligible patients who can switch plans outside AEP
• Licensed agent status: Recently became licensed to provide deeper guidance on Medicare supplements and non-Part D questions.

Why Patients Choose Her Pharmacy

"Accessibility is the primary thing," Traci shared. "They can come in. They know we'll take care of them. They trust us. They're already coming here, and we make it pretty seamless."

That trust extends beyond prescriptions. "In rural communities, there's just not a lot of resources for good trusted information. They trust us as independent pharmacists and their trusted medical professional in town."

The Retention Advantage

The financial impact of Medicare plan comparisons extends far beyond helping individual patients find better coverage. Patients who receive plan comparisons are 28% more likely to continue filling at their pharmacy the following year.

For pharmacies that have dropped PBM contracts or are considering doing so, this retention strategy is critical. "Identify those patients that are impacted early and help them switch to in-network plans before year end," Marvin advised.

Practical Implementation Strategies

Identifying Priority Patients

Focus your plan comparison efforts on:

1. High-volume Medicare patients (4+ prescriptions monthly)
2. Patients with chronic conditions
3. Patients on plans where you’re not contracted for medical billing
4. Patients filling below-cost prescriptions
5. Patients who quality for long-term care at home

Managing the Workflow

Traci's process has evolved over her decade of offering comparisons:

"For us, I do it outside of workflow completely. It doesn't take me long at all, especially for people that fill at our pharmacy—maybe five to ten minutes."

She schedules appointments rather than handling comparisons during busy prescription filling: "I'll typically do quite a few of them and then call the patient on the phone with an appointment, but I also have in-person 15-20 minute appointments."

Timing Considerations

While AEP officially begins October 15, Traci waits until around October 23 to start appointments. "I like to give it a little time for all the dust to settle because things change a little bit early on."

Community Outreach That Works

Traci's community engagement strategy demonstrates how pharmacies can build awareness year-round:

During Open Enrollment

• Text messages and phone campaigns to Medicare-eligible patients
• Facebook posts advertising free comparison services
• Direct mail to patients over age 65

Beyond AEP

• Medicare 101 classes for new beneficiaries
• Monthly senior center health screenings
• Vaccine clinics at community locations

"The more contact [you] have with the elderly, the more they trust you," Traci explained. "They're grateful for the extra service and help we offer them."

Separating Pharmacy and Broker Roles

For pharmacists considering becoming licensed agents, Traci offers practical guidance on managing dual roles:

"You do have to separate it and wear two different hats. I'll typically set up an appointment for the following day or later that day. You have to have a scope of appointment and follow all those rules."

She acknowledged the challenge: "It would be really hard if you're the only pharmacist. In the past, I've had that role, and I think it would be really hard."

Why Use EnlivenHealth Match as a Licensed Agent?

Even after becoming licensed with access to traditional broker platforms, Traci continues using EnlivenHealth's Medicare Match because:

1. Pharmacy-specific insights: “It shows us the reimbursement, the maximum cost from the pharmacy side.”
2. Patient cost predictions: “It predicts when they’re going to reach their out-of-pocket. I was hesitant last year, but it really happened. It was very accurate.”
3. Familiar workflow: “I like the report that prints, and I’m able to really go over that with them.”

Year-Round Opportunities

While AEP runs through December 7, smart pharmacies recognize that Medicare plan enrollment opportunities exist throughout the year:

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

MA enrollees can switch to another MA plan during the first quarter—an often-overlooked opportunity.

New to Medicare (Rolling)

Patients become eligible three months before turning 65 and can enroll throughout the year. "That's when I use it predominantly now," Traci shared about the opportunities tab in Medicare Match. "I'm able to see people turning 65 in the next three months."

Special Enrollment Periods

Dual-eligible and low-income subsidy patients can change plans outside standard enrollment periods.

The Strategic Imperative

Medicare Advantage plans aren't just another insurance option—they're a strategic gateway to sustainable pharmacy revenue in an era of crushing PDP reimbursement rates.

By understanding how to:

• Bill clinical services to the medical benefit
• Process OTC benefit cards
• Leverage enhanced LTCH reimbursement
• Align patients with plans that support your services

Independent pharmacies can transform Medicare plan comparisons from a seasonal service into a year-round profit center that strengthens patient relationships while diversifying revenue away from traditional prescription margins.

As Traci Bayer's experience demonstrates, this isn't about selling insurance—it's about being the trusted healthcare provider your community needs, equipped with the tools and knowledge to help patients navigate an increasingly complex Medicare landscape while building a more financially sustainable pharmacy.

The question isn't whether to embrace Medicare Advantage opportunities. It's whether you can afford to ignore them.

To watch the webinar on demand, click here!

________________________________________

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

‍