Aetna insureds see big hike in required copays for scripts

Island pharmacies no longer considered “preferred.”

Conroy Apothecary is no longer classified as “preferred” by Aetna.

Customers at all five Island pharmacies that accept Aetna’s Medicare Part D coverage faced an increase in their copays after Jan. 1. Aetna changed the Island pharmacies’ status from “preferred” to “standard tier.” That resulted in the hike in copay requirements.

A few weeks ago, Ed Grazda, of Chilmark, walked into Conroy Apothecary in West Tisbury expecting to pay $1 as usual for his blood-thinning medication. The bill was closer to $20.

“When I called Aetna, they said the preferred pharmacy is Walmart or by mail, which I don’t want to do,” Mr. Grazda told The Times. “For Island people to get on the ferry to go to Walmart for medicine is obscene.”

Mr. Grazda has calculated his new copay will add up to $740 a year for his medications.

“While I can afford the increase, it makes me mad that my meds bill is almost double from last year,” Mr. Grazda said in an email to The Times. “I am concerned about folks who cannot afford the increase.”

Pharmacist Tamara Conroy Hersh said she found out in November during an open-enrollment period that her pharmacy was no longer classified as “preferred” by Aetna. And, she added, no one contacted her to discuss the change.

“I can fill a prescription, but the copay is going to be much higher,” she said.

Ms. Hersh explained that pharmacies must meet specific requirements to service Medicare Part D customers.

“It’s a good thing, it will weed out pharmacies that aren’t taking care of their customers,” Ms. Hersh said. “But to do all the work for Medicare Part D and then not be preferred, that’s frustrating.”

Aetna spokesman Walter Cherniak confirmed that now no Island pharmacies are considered “preferred.” He explained in an email to The Times that the small numbers of Islanders who use Aetna’s Medicaid Part D insurance led to the change in the pharmacies’ status.

“First, the rates Aetna secures (negotiates) from pharmacies to participate in the preferred network must meet a requirement from the Centers for Medicare and Medicaid Services (CMS). This is the agency that runs Medicare,” Mr. Cherniak wrote.

“That requirement is that the reduction in patient cost-sharing associated with a pharmacy being listed as ‘preferred’ cannot result in an increase in CMS payments.”

In other words, he said, it cannot be more expensive to CMS for members to fill scripts at preferred pharmacies based on the rate Aetna and the pharmacy agreed to.

Essentially, Medicare won’t pay more, so the small pharmacy retains the lower deductible charge and struggles to fill the prescriptions economically and make a profit at the same time, so Aetna raises the cost-sharing requirement. Then the insured must pay more (dealing with what is then called a nonpreferred dispensary). The three players — Medicare, the pharmacy, the insured — share a problem, but only two of them share the increased cost.

“It comes down to senior citizens doing their homework when they choose a Medicare provider,” Ms. Hersh said. “Now they can’t make a change until the next open-enrollment period.”