Medicare in Sedgwick County: Everything Is on Cedar Street

Everything is on Cedar Street

In Julesburg, Colorado, Abts Pharmacy is at 121 Cedar Street. Sedgwick County Memorial Hospital is at 900 Cedar Street. The hospital is a Critical Access Hospital, a federal designation Medicare created for small rural hospitals.

One street. A hospital and a pharmacy, both in town, in a county of about 2,247 people.

That is a better position than a lot of places its size manage, and if you are the son or daughter reading this from somewhere three hours away, it is worth knowing before you start worrying. Most of what your parent needs is walkable.

This post is about the one part that is not settled by geography.

The county, in one number

About 18.9% of the United States is aged 65 or older. Sedgwick County is 31.2%.

Close to a third. It is one of the oldest counties in Colorado, and it is nothing like the parts of the state where Medicare marketing is aimed — Weld County, for comparison, runs 13.9%.

Which is why almost nothing written about Medicare is written for Julesburg, and why the plan comparison tools, the mailers and the call centres all quietly assume there is another pharmacy down the road.

What is fixed, and what resets every year

The hospital's Critical Access status is a federal designation. It attaches to the building, it is set by criteria, and it does not change because somebody changed insurance in November.

Abts Pharmacy being the only pharmacy in Julesburg is a fact about the town.

Neither of those is a decision anybody makes each autumn. But there is a third thing, and it does reset: whether a Medicare drug plan treats 121 Cedar Street well. That is a contract between a plan and a pharmacy, renegotiated year by year, and nobody sends you a note about it.

Medicare plans have contracts with in-network pharmacies, which Medicare describes as pharmacies that "have agreed to offer a discounted price for members of certain Medicare plans." Some plans go a step further and designate preferred in-network pharmacies, which in Medicare's own words "have agreed to charge less than other pharmacies in your plan's network." And if you buy drugs at a pharmacy outside the network, Medicare's wording is that you will "probably have to pay full cost."

In a town with two pharmacies, that is a comparison. In Julesburg it is closer to a verdict.

What you can settle from three hours away

This is the useful part if you do not live there, and the honest division is sharper than people expect.

You can do all of this remotely, without involving anybody:

• Get the plan's pharmacy directory for Sedgwick County, Colorado. Not the map tool — the directory is the document that states whether a pharmacy is preferred, in-network, or absent. Ask for it by that name.
• Look up 121 Cedar Street in it specifically. By address, not by town, and not by "is there a pharmacy nearby."
• Check the formulary — the plan's list of covered drugs and the tier each sits on — against the actual bottles. A plan can treat the pharmacy well and still have moved a prescription to a tier that costs more, or attached a rule requiring approval first.
• Ask what happens on a 2- or 3-month supply. Medicare notes that some pharmacies offer a 2- or 3-month supply of covered drugs and that some plans offer mail order for up to a 3-month supply. Those can be priced differently from each other.

You cannot do this remotely, and should not try:

Decide whether driving somewhere else is realistic. You do not know what that road is like in February, whether your father still drives after dark, or whether the trip costs him the entire day. He does. That judgement is his, and the fastest way to lose the argument is to make it for him.

The suggestion to be careful with

From a distance, mail order sounds like the obvious fix. It removes the drive, it arrives at the door, it is one less thing.

Sometimes it is right. But notice who it is convenient for. The person proposing it is not the one who has to phone a warehouse when a refill has not arrived and there are two tablets left in the bottle. Nobody at that warehouse knows your mother's name or notices that a new prescription sits badly with something she has taken for four years.

Abts is on Cedar Street. If something goes wrong on a Tuesday, that is a walk, and there is a person on the other end of it who has been filling her prescriptions for years.

Mail order is a real option and worth pricing. It is just not a neutral one, and it should not be the first thing out of your mouth.

One call, made together

Do not make this call for him. Make it with him, on speaker, and let him ask at least one of the questions.

1. "Is the pharmacy at 121 Cedar Street in Julesburg in this plan's network?"
2. "Is it a preferred pharmacy, or another network pharmacy?"
3. "What would a 90-day supply cost there, compared with mail order?"
4. "If it is not preferred under this plan, what is the nearest pharmacy that is?" — then get the town name, and let him tell you whether that is a real answer or a theoretical one.

Then take all four answers into the pharmacy and ask whether the picture matches what they see. They fill prescriptions under these plans every week.

The free counsellor nobody mentions

Colorado runs a State Health Insurance Assistance Program — SHIP — with counsellors trained on Medicare who do not sell plans and do not work for one.

888-696-7213.

No cost, no catch, nothing being closed at the end of it. There is also a companion program for suspected fraud and billing errors, at 800-503-5190.

This is a particularly good resource for the long-distance situation, because a counsellor can talk to your parent directly, in their own time, without it being their child telling them what to do. Sometimes that is the entire difference.

Where we come into this

Haven Health Plans was started by the pharmacists at Good Day Pharmacy. Good Day operates a network of local community pharmacies across Colorado, Wyoming and Nebraska, and Abts Pharmacy in Julesburg is one of them. The group is still growing.

So the suspicion is fair, and it deserves an answer before you have to raise it.

We do not pick plans around pharmacies. A recommendation rests on the medication list, the doctors and the budget. A pharmacy enters the conversation when the person tells us they want to keep theirs — and if the plan that fits the list best treats some pharmacy other than ours better, that is the answer you will get. Hold us to it.

What the pharmacy side is actually for is narrower than it looks from outside. It is that a pharmacist who has filled these prescriptions for nine years can tell you which of the four questions above matters in this particular case, because the list is in front of them while they answer.

Covered is not the same as workable. A pharmacist knows the difference.

And the standing rule, here and in everything else we write: nobody should stop, skip or reduce a medication on their own over a cost question. Changes go through the person who prescribed it. If cost is the real problem, say so plainly to the prescriber and to the pharmacist — there are usually more moves available than people expect, and none of the good ones involve stretching a prescription out.