Heights Pharmacy tells Medicaid recipients to use CVS

If you are a patient covered by Medicaid, your prescriptions have not always been filled by the Shelter Island Heights Pharmacy in recent months even though it is the only drugstore in town.

In December, Medicaid recipients told the Reporter they were informed they would have to contact a CVS pharmacy, which would require a trip to the North or South forks to get their medications.

Medicaid provides coverage to residents based on financial information, family size and other factors used to determine eligibility. Any pharmacy can withdraw from the Medicaid program or set limits on the number of Medicaid patients it can serve.

In the interim, the Heights Pharmacy has filled at least some of the Medicaid prescriptions, according to one recipient, who requested anonymity for privacy concerns.

After being told the pharmacy wouldn’t fill her prescriptions, she was recently able to fill one. But when she picked it up, she was told by a pharmacist that might not be the case the next time.

“I think that they still don’t have a very good handle on it, to say the least,” the woman said. The pharmacy will fill the prescription, but it’s just a matter of whether or not Medicaid will cover the cost, she said.

Her most recent Medicaid prescription was filled at the Heights Pharmacy and she was charged only her $20 co-pay. But other medications she’s been prescribed are expensive and she needs Medicaid coverage to afford them, she said.

“I will definitely have them filled off-Island because the cost difference will be tremendous,” she said. Having to take time and the expense of even the reduced resident ferry fares does pose a difficulty, she said.

“I know that they were grandfathered in for a bit, but I believe that time has expired,” she said,” referring to the time when the local pharmacy was still taking Medicaid prescriptions.

That’s also the case for some Island seniors. Census figures show 41% of residents here are seniors. Many are active, thriving, but some are frail and as Medicaid recipients, are financially pressed to pay travel expenses.

Most seniors have Medicare benefits, with most of the premium cost coming from their Social Security checks, and they have the option of adding a backup plan to either pay the estimated 20% of cost that Medicare doesn’t pay, or using a Medicare Advantage plan that covers most of their health care costs.

But Medicaid recipients have to qualify for that assistance if they can’t afford the costs associated with the Medicare Plans.

From the time Medicaid recipients first reported they were being told to take their prescriptions to CVS, the Reporter asked for a response from Stacey Soloviev, the new owner of the Pharmacy.

Ms. Soloviev didn’t respond directly, but her spokesperson, Jaret Keller of the Key Group Worldwide, asked that all questions be addressed to him. Many efforts were made to follow up with him, but he has not provided any statement about the reason Island Medicaid recipients are being told to take their prescriptions elsewhere.

It was learned Monday that help may be on the way for those unable to travel off-Island. A spokesperson for the New York State Department of Health (NYSDH) provided answers and, perhaps, a solution for those who would be unable to easily get their medications if the local pharmacy doesn’t extend coverage.

NYSDH Information Officer Monica Pomeroy reported that pharmacies aren’t required to participate in the New York State Medicaid program. Those who do are “required to fill Medicaid prescriptions as a condition of being an enrolled provider,” meaning a pharmacy that chooses to participate in the Medicaid program, Ms. Pomeroy said.

Understanding the challenges for Shelter Island Medicaid recipients, she said those prescriptions can be filled by a pharmacy that has a mail order service. Using that service would not incur added expense, she said.

CVS, which has stores on both the North and South forks has a mail order service but “It depends on what the patient’s Medicaid plan allows” since there are various levels of Medicaid coverage available, according to Amy Thibault, director of external communications for CVS.

Each Medicaid recipient interested in using the company’s mail order will have to check with the provider of their policy to determine if their specific coverage will extend to covering the mail order delivery.

In December, Assemblyman Fred Thiele Jr. (D-Sag Harbor) asked his staff to get clarification on the policy affecting Medicaid prescriptions. The legislator’s office concluded that a pharmacy agreeing to participate in the program could limit the number of recipients it would serve.

That would appear to be in conflict with Ms. Pomeroy’s statement that if a drugstore agrees to participate in the Medicaid pharmacy program, it has to accept those prescriptions.

The decision not to serve Medicaid recipients could be the result of several factors, Mr. Thiele said, including low reimbursement rate/dispensing fees and administrative burdens such as the time to process paperwork, or a lack of sufficient staff to handle the added work.

A participating pharmacy handling Medicaid prescriptions can’t refuse to fill a prescription because the patient is unable to meet a co-pay, Mr. Thiele said. “By-and-large it appears that pharmacies are able to make decisions about their patients with few restrictions,” he said. “There are even ‘cash only’ pharmacies which take no forms of insurance, public or commercial, as a means to avoid administration and dealing with other actors like pharmacy benefit managers,” he added.

Pharmacy benefit managers have been described as middlemen between drug manufactures and pharmacies.