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Courtesy of Crystal McEntire<\/p>\n
A drone photograph of the McEntire Ranch near Sweetwater, Okla. on March 31, 2025. <\/p>\n
McEntire and many other independent pharmacists place the blame for their financial challenges on pharmacy benefit managers, or PBMs. PBMs, which are usually listed on people\u2019s insurance cards, negotiate drug prices for large employers and insurance companies and maintain the list of drugs that are covered by insurance plans, giving PBMs control over how much money a pharmacy can make per prescription. Reimbursement rates have gotten so bad for some prescriptions that pharmacies are having to sell some at a loss.<\/p>\n
Dana Tilton, who owns Dana\u2019s Pharmacy in Spur, about 67 miles east of Lubbock, recently filled an insulin prescription that cost Tilton $414.21 to stock. The PBM reimbursed Tilton $403.16 and the customer didn\u2019t have to pay anything, meaning she lost $11.05.<\/p>\n
The Texas Tribune reached out to the country\u2019s biggest PBMs \u2014 Optum Rx, CVS Caremark and Express Scripts \u2014 which control 80%<\/a> of all prescription claims in the U.S. They replied they\u2019re doing all they can to support independent rural pharmacies, not put them out of business with unfair reimbursement rates.<\/p>\n \u201cPharmacy is the most accessed benefit in health care, and community and independent pharmacies are essential care providers, especially in rural and underserved communities,\u201d according to Optum Rx\u2019s statement. \u201cOptum Rx supports these pharmacies through cost\u2011based reimbursement aligned to manufacturer pricing actions.\u201d<\/p>\n \u201cLast year alone, CVS Caremark saved its clients $45 billion in prescription drug costs, and our client retention rate is between 98-99% every year,\u201d according to CVS Caremark\u2019s statement, adding they employ over 28,000 Texans, operate 750 Texas pharmacies and generate $46.9 billion in positive economic activity in the state each year.<\/p>\n Express Scripts did not reply to a request for comment.<\/p>\n Phoebe Terry for The Texas Tribune<\/p>\n A collection of stock bottles, used to fill individual prescriptions, on shelves at Hyland\u2019s Pharmacy in Wheeler. Reimbursement rates have gotten so bad for some prescriptions that pharmacies are having to sell them at a loss.\u00a0<\/p>\n Rural pharmacies are most acutely affected by this loss of profit because of their lower revenue streams compared to corporate and urban pharmacies. Now, rural pharmacies are taking on novel strategies \u2014 like cattle businesses and gift shops \u2014 to stay afloat.<\/p>\n PBMs are \u201cbusiness people. They\u2019re not pharmacists. It\u2019s a business to them. They\u2019re not as invested in these people as I am,\u201d Tilton said.<\/p>\n Both Hyland\u2019s Pharmacies and Dana\u2019s Pharmacy are preventing two counties from becoming pharmacy deserts. Without each of those businesses, several other neighboring counties that don\u2019t have pharmacies would also lose access.<\/p>\n Being a resident in a pharmacy desert means having<\/a> less consistent access to medications, vaccinations and pharmacist-led care. It also means worse medication adherence, leading to the worsening of chronic conditions and overall health outcomes, according to research by Ohio State University.<\/p>\n \u201cFor some of them, I took care of their grandma and grandpa, and I take care of their mom and dad\u2026 they\u2019re my friends and my neighbors,\u201d Tilton said. \u201cWhen you\u2019re working in a big chain or a big store in a big city, you don\u2019t know those people, and you don\u2019t know their lives like we do in these small towns.\u201d<\/p>\n \u201cWe\u2019ve got to have the cattle\u201d<\/p>\n Owning both businesses came naturally to McEntire. She grew up on a farm and when she started pharmacy school, she\u2019d spend weekdays taking courses and weekends at home, tending to her cattle with her husband.<\/p>\n McEntire is following in the footsteps of her parents, who also relied on two sources of income \u2014 a cattle business and an oil drilling business. They used both businesses as safety nets for each other. In the early-2010s \u2014 the first years she was operating both businesses \u2014 Hyland\u2019s revenue supported McEntire Red Angus\u2019 operation. Now, the cattle company keeps her pharmacy in business.<\/p>\n \u201cWhen the oil field was good, the cattle was bad, or when cattle was good, the oil field was bad,\u201d McEntire said of her parents\u2019 business model. \u201cI feel like, now, you\u2019ve got to be diversified. To be in the pharmacy business, we\u2019ve got to have the cattle.\u201d<\/p>\n Phoebe Terry for The Texas Tribune<\/p>\n Hyland\u2019s Pharmacy also sells Wheeler High School merchandise.\u00a0<\/p>\n McEntire isn\u2019t the only independent pharmacist who has turned toward other revenue streams to support her faltering pharmaceutical profits. Tilton\u2019s pharmacy in Spur, home to 900 people, sells prescription and over-the-counter drugs alongside hair products, clothing, gifts and other goods on an as-needed basis. If she knows there\u2019s an upcoming baby shower in town, for example, she\u2019ll stock up on baby gifts. She wants to start selling Botox injections to her customers, so she\u2019s obtaining a license.<\/p>\n \u201cIt gets leaner and leaner every year and there\u2019s more and more competition because of the big mail-order PBMs,\u201d Tilton said.<\/p>\n For both Tilton and McEntire, the most difficult aspect of staying open as an independent pharmacy owner are poor PBM reimbursement rates.<\/p>\n The exchange between a PBM and pharmacy starts when a customer hands their insurance card to the pharmacist; many insurance cards list the PBM company. When customers go to pay for a prescription, PBMs have already determined how much the insurer and customer is paying for the drug and how much the pharmacy is reimbursed for selling the drug.<\/p>\n In 2025, the parent companies of the three largest<\/a> PBMs in the U.S. were included within the top 13 companies on the Fortune 500<\/a>, which ranks the largest U.S. companies by revenue.<\/p>\n Because those PBMs control the vast majority of drug claims in the country, for many prescriptions, pharmacies have no choice but to accept the rates these PBMs give them. It\u2019s a \u201ctake-it-or-leave-it-deal,\u201d as Tilton put it, because it\u2019s the only opportunity to provide life-saving medication to many customers \u2014 even if that means selling medication at a loss.<\/p>\n \u201cThe pharmacist has absolutely no control whatsoever,\u201d Tilton said. \u201c[PBMs] know what\u2019s going on. We don\u2019t.\u201d<\/p>\n Rural pharmacies aren\u2019t the only institutions affected by PBM rates. PBM rates at any pharmacy \u2014 whether in a hospital, at a corporate-owned pharmacy or a mail-order pharmacy \u2014 have a high likelihood of being determined by one of these three PBMs.<\/p>\n \u201cIf you are smaller, if you are independent, if you have a more fragile revenue stream, you are more susceptible to the types of strong-arming that can happen when a larger entity comes into the system,\u201d Charles Miller, director of health and economic mobility policy at Texas 2036, a nonpartisan think tank, said. \u201cI would not say that it is a uniquely rural story \u2014 it is a disproportionately rural story.\u201d<\/p>\n Consequences of a rural pharmacy desert<\/p>\n Phoebe Terry for The Texas Tribune<\/p>\n Crystal McEntire, who owns Hyland\u2019s Pharmacy in Wheeler, talks with Danny Hardcastle, a regular customer, about a stock show her son recently attended.\u00a0<\/p>\n Rural pharmacies disproportionately serve older, lower-income populations<\/a> compared to their urban peers. They operate not as a storefront simply to get medication but also as a community hub, offering people in the area help on a variety of issues.<\/p>\n McEntire, for example, recently ordered a customer\u2019s favorite overalls for him because he doesn\u2019t have internet at home, nor a credit card. She\u2019s answered the questions of anxious people who just came from the hospital and were told they had cancer. In many cases, people will go to the pharmacy before the emergency room in dangerous medical situations, simply out of familiarity, McEntire said.<\/p>\n \u201cWe connect with them better. We don\u2019t just move on to the next patient,\u201d McEntire said.<\/p>\n McEntire and Tilton both credit the fear of creating a pharmacy desert as a major motivator to stay open. Tilton travels 24 miles to a neighboring pharmacy desert<\/a> \u2013 King County \u2013 to help fill prescriptions at a 60-bed nursing home, so shutting down her business would have ripple effects beyond her home in Dickens County.<\/p>\n Lack of access to a pharmacy forces people to go without medicine or make their medicine last longer, according to Ohio State University researchers<\/a>. Mail-order pharmacy is not a viable option for some rural Texans who lack broadband access.<\/p>\n McEntire had six customers leave Hyland\u2019s Pharmacy to get their prescriptions filled at corporate or mail-order pharmacies. But, she said, all six of those patients returned to Hyland\u2019s not long after.<\/p>\n McEntire believes this was because rural patients appreciate independent pharmacies that are better able to accommodate their unique needs. For example, one couple that left Hyland\u2019s returned after Walmart consistently filled only one of their prescriptions at a time, forcing them to make the two-hour-long journey to and from Walmart multiple times a week.<\/p>\n Phoebe Terry for The Texas Tribune<\/p>\n The sign in front of Hyland\u2019s Pharmacy in Wheeler.\u00a0<\/p>\n Independent rural pharmacies offer better customer service than their corporate and mail-order peers, McEntire said. One of her patients was prescribed a blood pressure medication containing a compound she\u2019s allergic to. McEntire recognized the issue and advocated for the safer medication to be covered by insurance.<\/p>\n \u201cI knew my patient, knew her problems,\u201d McEntire said. \u201cPharmacy is an industry that can kill you or cure you. If I give you the wrong medicine, it can kill you. If I give you the right medicine, I can cure you.\u201d<\/p>\n Tilton hasn\u2019t seriously considered closing down her shop. She\u2019s owned Dana\u2019s Pharmacy for 30 years and plans to retire in nine years when she turns 70. But if she can\u2019t find somebody to buy Dana\u2019s, she\u2019d rather run the pharmacy until she \u201cabsolutely can\u2019t do it anymore,\u201d because she doesn\u2019t want her community to go without a pharmacy.<\/p>\n McEntire, though, has considered closing her second pharmacy in Shamrock, also in Wheeler County. But she knows that if she did, her employees would lose out on their wages, McEntire said.<\/p>\n \u201cI know they need their payroll to put food on their table for their families,\u201d McEntire said. \u201cIt is a huge burden.\u201d<\/p>\n More transparency in reimbursement rates<\/p>\n Phoebe Terry for The Texas Tribune<\/p>\n Crystal McEntire, who owns Hyland\u2019s Pharmacy, counts out pills to fill a patient\u2019s prescription.\u00a0 <\/p>\n Texas lawmakers have passed several laws impacting the relationship between PBMs and pharmacies, but they\u2019ve done little to address the core issue of fairer PBM reimbursement rates.<\/p>\n One bill<\/a>, passed last year, provides protections for pharmacies in their contracts with PBMs. Another<\/a>, also passed last year, prohibits \u201cgag clauses,\u201d which previously prevented pharmacists from informing patients if their medication was more affordable to obtain elsewhere.<\/p>\n But pharmacists and advocates believe that more can be done to ensure pharmacies can run independently, without relying on other sources of income. RoxAnn Dominguez, president of the Texas Pharmacy Association, supported both bills but said state and federal lawmakers need to pass laws preventing PBMs from underpaying pharmacists and increasing PBM reimbursement rate transparency.<\/p>\n She noted some states, such as Ohio<\/a> and California<\/a>, are under a flat-fee PBM model, which pays pharmacies a fixed, transparent fee per claim. She thinks a similar system could be effective in Texas.<\/p>\n \u201cI think most people just want transparency,\u201d Dominguez said. \u201cIf everybody\u2019s getting paid the same, then what you\u2019re going to actually compete on is service, and who does the best by patients.\u201d<\/p>\n Many pharmacists and advocates hope for an overhaul of the PBM system. But Miller believes supporters of a PBM overhaul should be wary of placing the blame for the entire system\u2019s design on any individual person or organization.<\/p>\n \u201cA common thing is to look at a PBM and say, \u2018we don\u2019t like what\u2019s happening with PBMs,\u2019 and the next natural conclusion would be to say, \u2018well, that PBM is acting poorly\u2019 or \u2018we don\u2019t like it,\u2019\u201d Miller said. \u201cUltimately, we need to look at the rules that we have designed around PBMs, and if we don\u2019t like how they\u2019re behaving, it\u2019s probably because we set up a poor system.\u201d<\/p>\n In the meantime, Tilton and McEntire will continue to try and keep their pharmacies afloat through their gift shops and cattle businesses.<\/p>\n Recently, plans for a data center near Spur by an artificial intelligence company were approved. Tilton is excited for the prospect of new businesses coming in as a result. But this, too, may attract corporate pharmacies to the area, posing a potential threat to her business.<\/p>\n \u201cThat\u2019s part of their work method \u2014 trying to run us little guys out.\u201d Tilton said.<\/p>\n Phoebe Terry for The Texas Tribune<\/p>\n Crystal McEntire and April Goad talk about Hyland\u2019s Pharmacy\u2019s boutique. Goad manages Hyland\u2019s Pharmacy\u2019s boutique part time alongside teaching high school students.\u00a0 <\/p>\n Disclosure: Texas 2036 and Texas Pharmacy Association have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune\u2019s journalism. Find a complete\u00a0list of them here<\/a>.<\/p>\n![\"A](\"https:\/\/www.newsbeep.com\/ie\/wp-content\/uploads\/2026\/03\/1774757893_160_.jpeg\"\/)
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