Express Scripts Cut Off a Rural Pharmacy. A DPC Doctor and Mark Cuban Are on the Town Hall Panel.
Mark Cuban is joining by video. That’s one signal a local pharmacy dispute has grown into something larger.
A town hall scheduled for Tuesday, June 23 at Martella’s Boswell Prescription Center in Boswell, Pennsylvania is set to bring together physicians, pharmacists, county officials, and the founder of Cost Plus Drugs. The subject is a contract termination roughly a year old: Express Scripts, the pharmacy benefit manager Cigna owns, dropped Martella’s Pharmacy from its network. Patients covered by Highmark and UPMC plans in Cambria, Somerset, and Westmoreland counties lost in-network access to their local pharmacy. The town hall is the work of Pharmacists United for Truth and Transparency, a national pharmacists’ advocacy group.
Dr. Zane Gates is one of the panelists. He’s a physician and pharmacist, and the co-founder of Gloria Gates CARE, a direct primary care network in Blair County that serves Medicaid patients, Medicare patients, people with ACA marketplace plans, and members who pay a flat monthly subscription for comprehensive care with no copays and no deductibles. He named the practice after his mother, who died because she lacked adequate healthcare coverage.
His argument is the same argument behind DPC. “It’s more expensive to process the drug (through insurance) than to just buy it straight up,” he told a reporter previewing the town hall, according to Yahoo News. He also said pharmacy benefit managers “don’t exist anywhere else in the top economically developed countries in the world, except for the United States,” which is what prompts his question about why they exist here.
Who Gets Hurt When a PBM Drops a Pharmacy
Somerset County Commissioner Pamela Tokar-Ickes offered two numbers: nearly 10,000 Somerset County residents rely on Medicare, and nearly 24,000 in neighboring Cambria County. For those patients, a contract termination isn’t an administrative inconvenience. Many live in rural areas where the nearest alternative pharmacy requires transportation they don’t have. Losing in-network access at the only pharmacy within a reasonable drive can mean losing access to their medications.
Pharmacists United for Truth and Transparency puts three companies at the center of the prescription market: Express Scripts, CVS Caremark, and OptumRx. Those three collectively process roughly 80% of prescription drug claims nationally. That concentration gives each company significant control over which pharmacies survive in a given area. An independent pharmacy that loses a PBM contract often loses the insurance reimbursement it needs to stay open.
Independent pharmacies have been losing ground for years as PBM reimbursement rates compress and contract terms favor large chains. In rural communities, when that happens, the alternatives often don’t exist.
Where DPC and Direct Pharmacy Overlap
Gloria Gates CARE covers many generic medications inside its monthly membership, but it doesn’t dispense most of them itself. The practice’s own page lists onsite clinical pharmacists and a stock of common acute medications, and says generic medications are “provided by participating independent pharmacy partners.” Gates told Yahoo News he wants Martella’s to be one of those partners: “We provide generic drugs and we want to work with Martella’s Pharmacy to do that with no co-pays and no deductibles.” That arrangement takes the copay and the deductible out of the transaction, but the prescription still gets filled at a community pharmacy — the same kind of pharmacy a PBM can drop.
Mark Cuban’s Cost Plus Drugs works from the same starting point, but in the pharmacy lane. The company buys drugs directly at manufacturer prices and posts costs transparently online. A medication that costs hundreds of dollars when processed through a PBM-negotiated insurance plan often costs a few dollars through Cost Plus. The model works precisely because it skips the middlemen.
The alignment between DPC and direct-pay pharmacy isn’t coincidental. Practices that operate outside the insurance billing system tend to attract patients and physicians who’ve reached the same conclusion: the intermediary layer adds cost without adding care. When a PBM squeezes an independent pharmacy out of its network, it hits exactly the patients who were already trying to find a different path.
Gates is asking about the pharmacy counter the question DPC physicians ask about primary care every day: why does the middleman exist? His training as both a physician and a pharmacist gives him an unusual vantage point on both sides of the same problem.
What This Means
For DPC practices, pharmacy access sits just outside the territory the model directly controls. A practice can deliver primary care entirely outside insurance billing, but the moment a patient needs a prescription filled at an outside pharmacy, the PBM layer is back.
Practices that dispense in-house are somewhat shielded from this. Practices that route medications through partner pharmacies are not, and that includes Gloria Gates CARE: its generic coverage runs through participating independent pharmacies, which puts its members on the same side of the line as Martella’s customers. A practice in that position is one PBM decision away from a problem it had no hand in creating and can’t negotiate its way out of.
The Boswell town hall is about one pharmacy in one county. The dynamic it exposes is not. PBMs have faced bipartisan congressional scrutiny for years, and the pressure has grown as consolidation continues. What’s changed is that DPC physicians are now showing up as part of the coalition making that case publicly.
Gates built his practice around his mother’s death. He is speaking at a town hall a pharmacists’ group called because a PBM cut off the kind of independent pharmacy his model depends on. The thread connecting those two things is the same one that runs through most of why DPC practices exist: the system keeps inserting layers between patients and the care they need. Pharmacies are the latest front.