Identifying Medicare Eligible Patients

Overview

The Medicare Eligible Patients list helps pharmacy teams identify patients who may benefit from a Medicare plan review. The list includes Medicare-eligible patients and provides filters and patient-specific information that can help prioritize outreach efforts.

Access the Medicare Eligible Patients List

Select Patients from the navigation menu.
Select Medicare Eligible

Patient Status Categories

Patients are organized into the following categories:

Plan Review Eligible: Patients who are eligible for a Medicare plan review.
Completed: Patients who have completed a Medicare plan review.
Declined: Patients who declined participation in a Medicare plan review.

Enrollment Filters

The Enrollment filter helps users focus on patients based on their Medicare enrollment status.

Open Enrollment

During the Annual Open Enrollment Period (October 15 through December 7), the default filter displays patients who meet the criteria for the current year's open enrollment period

Outside Enrollment

Outside of Open Enrollment, the default filter displays patients who are within three months before or three months after their 65th birthday month and may be eligible to enroll through their Initial Enrollment Period (IEP).

Average Copay

The Average Copay column displays the patient's average out-of-pocket copay per medication over the previous 12 months. This information can help identify patients who may benefit from comparing Medicare plan options.

Income Filter

The Income filter helps pharmacy teams identify patients who may qualify for Medicare's Low-Income Subsidy (LIS), also known as Extra Help program. This filter evaluates prescription claims and copay patterns from the patient's medication history to identify patients who may benefit from additional assistance with prescription drug costs.

Patients identified through this filter may be good candidates for a Medicare plan review, as they could have opportunities to reduce out-of-pocket costs or explore plan options that better align with their financial needs .

How the Filter Works

The Income filter reviews prescription activity from the previous 12 months and applies logic based on Medicare Low-Income Subsidy cost-sharing guidelines. Using the data available within Outcomes, Medicare Plan Finder identifies patients whose prescription copay patterns may be consistent with LIS eligibility. The criteria used by Medicare Plan Finder are reviewed and updated as Medicare guidance changes

Important

The Income filter should be used as a patient outreach and prioritization tool, not as a determination of LIS eligibility.

Medicare Plan Finder does not have access to all information used by Medicare to determine Low-Income Subsidy eligibility, including a patient's full enrollment, subsidy, and financial information. To help identify patients who may benefit from additional assistance, the Income filter analyzes available prescription claims data and applies assumptions based on Medicare LIS cost-sharing guidelines. Because eligibility cannot be confirmed using prescription data alone, the filter may not identify all LIS-eligible patients and some patients who qualify for LIS may not be flagged by the filter