When Your Town Has One Pharmacy, Your Drug Plan's Network Is the Whole Question

The pharmacy on Cedar Street

In Julesburg, Colorado, the pharmacy is Abts Pharmacy, at 121 Cedar Street. That is not a recommendation. It is a description. Abts is the only pharmacy in town.

The same is true in Guernsey, Wyoming, where Register Cliff Pharmacy sits at 437 West Whalen Avenue. It is true in Palisade, Colorado — Palisade Pharmacy, 707 Elberta Avenue. It is true in Colorado City, Colorado, where Valley Pharmacy is at 4493 Bent Brothers Boulevard, and where the next town over, Rye, has no pharmacy at all. Eaton and Yuma, both in Colorado, each have exactly one as well, and in both towns it is a Good Day Pharmacy.

If you live in one of those places, a question that is a minor convenience for somebody in Denver is, for you, the whole question.

What "network" means on a Medicare drug plan

Every Medicare drug plan has a pharmacy network. That is true whether the coverage is a standalone Part D plan — Part D is the part of Medicare that covers prescription drugs you pick up yourself — or the drug coverage built into a Medicare Advantage plan. Medicare requires plans to build a network and requires that network to be adequate for the area the plan is sold in.

Medicare describes in-network pharmacies as ones that "have agreed to offer a discounted price for members of certain Medicare plans." Within that network, plans generally sort pharmacies into two positions:

• A preferred pharmacy is one the plan has a closer arrangement with. Medicare's own wording is that preferred in-network pharmacies "have agreed to charge less than other pharmacies in your plan's network."
• A standard network pharmacy is in the network, and the plan will cover your prescription there, but your share is generally higher than at a preferred one.

And then there is out of network, which is a different situation entirely. In Medicare's wording, at a pharmacy outside the network you will "probably have to pay full cost for the drugs."

One note on vocabulary, because it causes arguments that do not need to happen. Plan documents commonly use the word standard for a network pharmacy that is not preferred. Medicare's own site never uses that word — its terms are "preferred in-network" and "other pharmacies in your plan's network." Same distinction, two sets of words. Know both and you will not get turned around by a phrase.

Here is the part that gets lost. A plan can be perfectly good, priced sensibly, cover every drug on your list, and still put the only pharmacy in your town in the standard tier rather than the preferred one — or leave it out of the network altogether. Nothing about that is illegal or unusual. Networks are built county by county and contract by contract, and the plan that made the best arrangement in Fort Collins did not necessarily make one in Sedgwick County.

Why the arithmetic is different in a small town

In a city, a pharmacy outside your plan's preferred tier is a mild annoyance. You look at a map, you find a preferred one two miles the other way, you move your prescriptions and you are done by Thursday.

In Julesburg, there is no other way. The alternatives are a drive to another town or mail order.

We are not going to print a mileage here, because we have not measured the roads and we are not going to invent a number. You know your own drive better than we do. What we will say is this: the drive is long enough that in these towns it is not a real substitute for the pharmacy on Main Street, and everyone who lives there already knows it.

Mail order is a genuine option and for some people it is the right one. It is also a different relationship. Nobody at a mail-order warehouse is going to notice that your new blood pressure prescription does not sit well with something you have been taking for four years. Nobody there knows your name. And when a refill has not arrived and you have two tablets left, the phone number you call is not in your town.

So in a one-pharmacy town, "is my pharmacy preferred under this plan" is not a footnote on the enrollment decision. It is close to the entire decision.

These towns are older than the country is

This matters because the people it affects are not a small group.

Across the United States, about 18.9% of the population is 65 or older. In the counties we are describing, the figures look nothing like that:

• Niobrara County, Wyoming — 31.7%
• Sedgwick County, Colorado — 31.2%
• Kimball County, Nebraska — 30.6%
• Platte County, Wyoming — 29.2%
• Goshen County, Wyoming — 27.0%
• Mesa County, Colorado — 23.5%
• Pueblo County, Colorado — 21.8%

Five of those counties run somewhere between 27% and 32% aged 65 and older. For comparison, Weld County, Colorado — Greeley, Eaton, Johnstown — runs 13.9%.

So the places where the pharmacy question is hardest are also the places with the highest concentration of the people it lands on. That is a strange fact, and it is why we are writing this post rather than another one.

The health care that is already nearby, and the health care that is not

It helps to know what is actually in town, because it shapes how much the pharmacy is carrying.

In Julesburg, Sedgwick County Memorial Hospital is right there at 900 Cedar Street — a federally designated Critical Access Hospital, which is a category Medicare created specifically for small rural hospitals.

In Guernsey, there is a clinic and no hospital. The nearest hospital is Platte County Hospital in Wheatland, also a Critical Access Hospital.

In Palisade, there is a clinic. The hospitals are in Grand Junction.

In Colorado City, there is a clinic — UCHealth Family Medicine, at 4491 Bent Brothers Boulevard, on the same short stretch of road as the pharmacy. The hospitals are in Pueblo.

In four of those towns, then, the pharmacist is the health professional you can reach on foot. That is worth factoring in before you sign something that changes where you fill prescriptions.

What to ask before you enroll

Whether you do this yourself, with a family member, or with someone else, these are the questions that matter, in this order.

1. Is my pharmacy in this plan's network at all? Not "is there a pharmacy nearby." Ask by name and by street address, because a plan's pharmacy finder will happily show you a pharmacy in a town forty minutes away and call it network coverage.
2. Is it preferred or standard? These are different, and the plan's own materials will tell you which. If the answer is standard, that is not automatically a reason to walk away — but you should know it before January, not in February.
3. What happens on a 90-day fill? Medicare notes that some pharmacies may offer a 2- or 3-month supply of covered drugs, and that mail order can run up to a 3-month supply. Those are not necessarily priced the same. If driving is hard for you, this question is worth more than it looks.
4. If my pharmacy is not preferred under this plan, what is the nearest one that is? Get the town name. Then decide whether that answer works in your actual life, in February, in the snow.

A plan is not wrong for putting your pharmacy in the standard tier. It is only wrong for you if nobody told you before you enrolled.

The free help almost nobody uses

Every state runs a State Health Insurance Assistance Program — SHIP — with counselors trained on Medicare who do not sell anything and do not work for a plan. It is free. It exists specifically for this. Most people entitled to it have never heard of it.

• Colorado — 888-696-7213
• Wyoming (Wyoming State Health Insurance Information Program) — 1-800-856-4398
• Nebraska (Nebraska SHIP & SMP) — 1-800-234-7119

Write the one for your state on the inside of a cupboard door. It is a genuinely useful number and it costs nothing to call.

Where we come into this

Haven Health Plans was started by the pharmacists at Good Day Pharmacy. Good Day now operates a network of local community pharmacies across Colorado, Wyoming and Nebraska, and the group is still growing. In several of those towns it is the only pharmacy left.

Which means we have to say the next part out loud, because a sensible person is already thinking it.

We do not pick plans around pharmacies. A recommendation rests on your medications, your doctors and your budget. A pharmacy enters the conversation only when you tell us you want to keep yours — and if the honest answer is a plan that works better somewhere other than one of ours, that is the answer you will get.

The reason the pharmacy side matters is different from what you would guess. It is not referral volume. It is that a pharmacist who has filled your prescriptions for nine years can tell you which questions on the list above actually apply to you, because they have your list in front of them.

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

One last thing, and it applies to every post we write: do not stop, skip or reduce a medication on your own because of anything you read about cost, here or anywhere. Changes go through the person who prescribed it. If cost is the problem, say so out loud to your prescriber and to your pharmacist — there are usually more options than people expect, and none of them start with skipping doses.