Medicare Open Enrollment season runs until Dec. 7, and changes that exclude independent pharmacies from preferred pharmacy networks means that the Part D drug plan you used in the past may not be the most cost-friendly option if you are a patient at an independent pharmacy.
“Medicare Part D is the part that covers your drugs,” said Lucas Smith at BV Drug, one of Buena Vista’s two independent pharmacies. Part D is administered by third-party pharmacy benefit managers, and “What these PBM’s have chosen to do next year is to not allow any independent pharmacy, any community pharmacy, throughout the whole country, into their preferred network.”
What that means for patients is that many prescription drug plans may cost more out-of-pocket when using a pharmacy outside that plan’s preferred pharmacy network.
“What being in a preferred network means is that the patient will usually have a lower copay if they went to a preferred pharmacy,” Smith said. “Two in particular, SilverScript and Wellcare, have said, no matter what, no matter how we negotiate, they’re not allowing us to be in this preferred network … That hurts, especially in rural areas where there aren’t a lot of options. A patient might have to go to an independent pharmacy no matter what, and they’re going to be forced to pay more for their medication.”
That’s a big deal for seniors on fixed incomes.
“Medicare D is based on the drugs you take, so Joe is on different drugs than Mary, so Joe may need a different plan than Mary,” said Rebecca Seaman, the pharmacist and owner of Shavano Pharmacy in LaGree’s Food Store. “People get married to their plans, and it scares them because they think there’s a lot of work involved (in switching to a different plan), but there really isn’t.”
In one case, Seaman found a plan for a patient that would reduce his copay for an inhaler from $280 to $41.
“He will have to meet his deductible, and he’ll do that in January and February because he gets it monthly, but then by March or April, he’ll be paying a $41 copay,” Seaman said. “That’s a huge savings. And it’s still the same premium a month and it’s still the same deductible.”
In Chaffee County, pharmacies that are not independent are City Market in Buena Vista and Walmart and Safeway in Salida.
The changes take effect on Jan. 1, 2021. In the meantime, independent pharmacists like Smith and Seaman are sitting down with patients to help them navigate the often confusing world of health insurance and find drug plans that are still affordable outside of a preferred pharmacy network.
The medicare.gov website also offers a tool that allows you to compare plans based on the drugs you take and the pharmacies in your area.
“A lot of (our patients), we’re switching to plans that maybe we are preferred in, or maybe it just works out that they’re covered better,” Smith said. “For example, one patient, if they went with Silverscript and they went to Safeway, their out of pocket expenses for the whole year would be $87, estimated, whereas if they kept Silverscript and went to me, it would be $820. Which, based on that person’s medication, it would be worthwhile for them to just not even get insurance and pay our own cash discount, because it would be cheaper than the $820 that the insurance would be charging them.”
Unfortunately for some patients, “there isn’t a good alternative. They’re pretty much forced to change (pharmacies) even if they don’t want to. Money is a big factor,” Smith said.
In Seaman’s view, this policy amounts to the PBM’s encouraging patients to use one pharmacy over another.
“We’re told, legally, from Medicare, that we’re not supposed to steer people. But, legally, they’re not either,” she said. “They’re not supposed to steer, but they are steering, because we all talk with our pocketbook. If they come to my pharmacy and I’m not preferred, their copay might be $30, but if they go to City Market or Walmart, their copay may be $10. So they are steering because they’re saying, ‘You get a cheaper copay here, as a preferred provider.’”
Smith said, “It’s not fair. They’re taking actions to destroy independent pharmacies, which, especially in rural areas, are a vital part of the community,” Smith said. “Currently there are little, or limited, actual regulations against these big entities.”