When Express Scripts Cut Off a Rural Pharmacy, a DPC Doctor Called a Town Hall. Mark Cuban Showed Up.

Mark Cuban was joining by video. That’s one signal a local pharmacy dispute has grown into something larger.

A town hall at Martella’s Boswell Prescription Center in Boswell, Pennsylvania drew physicians, pharmacists, county officials, and the founder of Cost Plus Drugs last week. The subject was a contract termination: Express Scripts, the pharmacy benefit manager Cigna owns, had 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.

Dr. Zane Gates was one of the organizers. 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 at the town hall was the same argument behind DPC. “It’s more expensive to process the drug through insurance than to just buy it straight up,” he told attendees, according to Yahoo News. He noted that pharmacy benefit managers don’t exist as an intermediary layer in other developed countries, which prompted his question about why they exist here.

Who Gets Hurt When a PBM Drops a Pharmacy

Somerset County Commissioner Pamela Tokar-Ickes offered a number: roughly 34,000 county residents rely on Medicare. 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, which organized the event, 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 operates its own dispensing model. Members get medications included with their monthly subscription at no extra cost. That’s part of what distinguishes the practice from a traditional primary care office: by building pharmacy access into the membership, it removes the prescription-to-PBM step entirely for the medications it can carry.

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, at the town hall in Boswell, was asking a 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 include dispensing or partner with direct-pay pharmacies are somewhat shielded from this. Members at Gloria Gates CARE get medications through the practice, which means a PBM contract dispute at a regional pharmacy chain doesn’t reach them. But practices that rely on patients filling prescriptions at community pharmacies are one PBM decision away from a problem they had no hand in creating.

The Boswell town hall was about one pharmacy in one county. The dynamic it exposed 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 organized a town hall because a PBM cut off a pharmacy his patients depend 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.