Webinar Summary: Reclaim Your Revenue: Fighting Low Reimbursement Rates with Medicare Plan Comparisons

November 24, 2025

On September 24th, 2025, EnlivenHealth partnered with American Pharmacies for a webinar titled “Reclaim Your Revenue: Fighting Low Reimbursement Rates with Medicare Plan Comparisons.” The event explored how independent pharmacies can navigate crushing reimbursement pressures while building stronger patient relationships through Medicare plan comparisons. With speakers Marvin Guardado (Senior Manager of Customer Enablement at EnlivenHealth), Jeff Jacobs (Vice President of Analytics & Clinical Services for American Pharmacies), and Jenna Domzalski de Rios (owner and pharmacist at Nowell Pharmacy in New Mexico), the session revealed both the harsh realities pharmacies face and the strategic opportunities available to those willing to adapt.

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The Perfect Storm: What Changed in 2024

January 2024 brought seismic shifts to Medicare Part D reimbursement. While the industry celebrated the elimination of DIR fees, few pharmacies were prepared for what came next.

The ESI Crisis

Millions of covered lives migrated to Express Scripts, with many pharmacies seeing ESI Part D patient volume surge by 300-600%. The real shock came from aggressive brand reimbursement rates that made profitability nearly impossible:

• Regular day supply: AWP minus 25.5%
• Extended day supply: AWP minus 30.5%

To break even at these rates, pharmacies would need cost of goods at minus 10.6% or minus 11.3%—a nearly impossible threshold that forces pharmacies to sacrifice margin on generics just to stay afloat.

Humana Followed Suit

Historically the top brand payer, Humana implemented similar changes with brand rates of AWP minus 21.7%, requiring net costs around minus 6% to break even. Combined with high-demand GLP-1 medications, these dynamics likely contributed directly to many 2024 and 2025 pharmacy closures.

The 2026 Outlook: Musical Chairs in Medicare

If 2024 was challenging, 2026 promises even more disruption. According to broker partner HP One, national carriers are scaling back rather than competing for growth:

• UnitedHealth: Expected to orphan approximately 600,000 members
• Aetna: Displacing around 150,000 members
• Regional players: Vermont Blue Cross and Sonder in Georgia have fully exited markets

In total, millions of patients will need to find new plans—but carriers aren't aggressively recruiting. This creates a critical gap that community pharmacies can fill.

The Medicare Advantage Opportunity

While PDP (Prescription Drug Plan) options continue to shrink, Medicare Advantage plans are growing rapidly. Currently, 58% of Medicare beneficiaries are enrolled in MA plans, with projections reaching 64% within ten years.

Why This Matters for Pharmacies

Medicare Advantage plans open doors to multiple revenue streams:

1. Clinical Services Billing: Pharmacies can bill Med Sync consults to MA plans using CPT code 99212, earning approximately $30 per consult monthly and creating subscription-like revenue that can transform unprofitable patients into profitable relationships.
2. OTC Benefits: Many MA plans, especially dual special needs plans, offer OTC cards that patients can redeem at independent pharmacies through processors like InComm, United's S3 division, or NationBenefits.
3. Better Prescription Reimbursement: Approximately 75% of MA plans offer $0 premiums on drug benefits, giving patients the affordability they want while opening access to plans that reimburse pharmacies more fairly than WellCare's aggressive rates.

Real Results from Real Pharmacies

Jenna Domzalski de Rios, owner of Nowell Pharmacy, has been offering Medicare plan comparisons for over a decade. Last year alone, her pharmacy helped more than 100 patients submit online enrollment applications through the EnlivenHealth Match platform.

Her approach includes:

• Monthly senior center classes offering blood pressure screenings, A1C testing, and medication education
• Proactive outreach during Annual Enrollment Period with pre-created patient lists
• Excel sheets identifying patients on poorly reimbursing plans
• Special focus on dual-eligible patients who often don't realize they should review their coverage

The Impact

“It really takes a lot to build trust with the elderly,” Jenna explained. “The more that we have those points of touch, they trust [us] more. We’ve gained more people coming into the pharmacy, but we’ve also gained [the satisfaction] of being able to just help them as well.”

One memorable case: A WellCare patient paying large brand co-pays and hitting the donut hole was switched to an AARP plan, dramatically reducing their premium and out-of-pocket costs. During the conversation, Jenna also helped them qualify for dual eligibility benefits they didn't know existed.

The Retention Advantage

The data is compelling: 97% of patients who receive plan comparisons continue filling at their pharmacy the following year, compared to just 76% who don't. That's nearly 25% higher retention—a critical advantage when every patient relationship matters.

Plan comparisons also create natural pathways to additional services. The conversations uncover pain points around affordability, adherence challenges, and out-of-network providers—opening doors to clinical consultations, adherence programs, and front-end sales opportunities.

Strategic Recommendations for 2026

With Annual Enrollment Period approaching, pharmacies should:

• Limit 90-day brand fills for Part D patients: When appropriate, more 30-day fills mean more patient touchpoints and opportunities to showcase revenue-driving services.
• Focus on cumulative growth: Add profitable solutions like nutrient depletion counseling, OTC benefit maximization, and medical billing without abandoning what's already working.
• Target dual-eligible patients: These patients often have poorly reimbursing plans but may qualify for better options—for them and for the pharmacy—that they don't know about.
• Screen new patient intake: With chain closures creating patient displacement, be selective about which patients you take on—and help them find suitable plans during the onboarding process.
• Build broker relationships: Partner with licensed insurance agents who can handle the enrollment complexities while you focus on patient care.

The Bottom Line

Medicare plan comparisons aren't just about helping patients find better coverage—they're about strategically positioning your pharmacy for sustainable revenue in 2026 and beyond. The work you do during Annual Enrollment Period sets the foundation for clinical services, patient retention, and optimized reimbursement throughout the coming year.

As Jeff Jacobs from American Pharmacies emphasized: "Match is effective and affordable and includes strong support when you need it." More importantly, it considers both the patient and the pharmacy—a win-win approach that independent pharmacies desperately need in today's challenging environment.

The question isn't whether you can afford to offer plan comparisons. It's whether you can afford not to. For more information about EnlivenHealth Match, visit enlivenhealth.co.

To watch the webinar in its entirety, click here!