Forced to sell at a loss, rural Texas pharmacies seek new survival tactics

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Rural independent pharmacies in Texas are looking for new ways to stay open as pharmacy benefit managers, or PBMs, negotiate drug coverage and reimbursement in ways that pharmacy owners say leave them unable to cover costs. In the latest accounts from the Texas Panhandle and West Texas, pharmacists described selling certain prescriptions at a loss and said they have had to diversify into other lines of business to keep medication access from collapsing in remote counties.

Dana Tilton, who owns Dana’s Pharmacy in Spur, said she recently filled an insulin prescription that cost her $414.21 to stock, while her PBM reimbursed her $403.16 and the patient did not have to pay. “Pharmacy is the most accessed benefit in health care, and community and independent pharmacies are essential care providers, especially in rural and underserved communities,” Optum Rx said in a response to an inquiry, adding that it supports independent pharmacies through “cost‑based reimbursement aligned to manufacturer pricing actions.”

Other PBMs offered differing responses. CVS Caremark said it “saved its clients $45 billion in prescription drug costs” last year, and it said its client retention rate is “between 98-99% every year.” CVS Caremark also said it employs over 28,000 Texans, operates 750 Texas pharmacies, and generates $46.9 billion in positive economic activity in the state each year. Express Scripts did not respond to a request for comment.

Pharmacy owners and advocates say the financial problem is especially acute in rural areas because independent shops often have lower revenue streams than corporate or urban pharmacies. McEntire, who owns two Hyland’s pharmacies in Wheeler County, described the daily rhythm of running a ranch and working at the pharmacy, including driving about 26 miles to Wheeler County’s Hyland’s Pharmacy. She said, “It’s all in your mindset, because it is a lot,” and she described switching her focus between tending cattle and handling patients at the pharmacy.

McEntire said profits from her pharmacy declined after opening in 2009, and that she used her cattle business—McEntire Red Angus, located in Sweetwater, Okla.—to float the pharmacies. She described the rationale as diversification learned from her family, saying her parents used multiple revenue sources, including ranching and oil drilling. “When the oil field was good, the cattle was bad, or when cattle was good, the oil field was bad,” McEntire said. “I feel like, now, you’ve got to be diversified. To be in the pharmacy business, we’ve got to have the cattle.”

Tilton said she also needs the pharmacy to remain viable because closing it would affect more than one address. Both Hyland’s and Dana’s, she said, are preventing two counties from becoming pharmacy deserts, areas where residents have to travel farther to reach a pharmacy. Tilton said she travels 24 miles to a neighboring pharmacy desert, King County, to help fill prescriptions at a 60-bed nursing home, warning that the ripple effects of losing a pharmacy can extend to nursing facilities and nearby communities.

Rural pharmacy deserts, according to the Texas Tribune report, can reduce consistent access to medications and pharmacist-led care and can worsen medication adherence, according to research by Ohio State University. Tilton tied her willingness to keep working to the relationships she has built in small towns, saying: “For some of them, I took care of their grandma and grandpa, and I take care of their mom and dad… they’re my friends and my neighbors.” She said large chains or big-city stores do not offer the same familiarity with patients’ lives and concerns.

In both Spur and Wheeler County, owners described diversification beyond prescriptions as a survival mechanism. Tilton’s pharmacy, which serves a town of about 900 people, sells prescription and over-the-counter drugs alongside items such as hair products, clothing, gifts, and other goods “on an as-needed basis,” the report said. She said she wants to add Botox injections and is obtaining a license, and she said, “It gets leaner and leaner every year and there’s more and more competition because of the big mail-order PBMs.”

Advocates and Texas lawmakers have passed some measures they say can reduce pressure on independent pharmacies, including laws passed last year that provide protections for pharmacy contracts with PBMs and that prohibit “gag clauses” that previously prevented pharmacists from informing patients if their medication was more affordable elsewhere. RoxAnn Dominguez, president of the Texas Pharmacy Association, supported both bills but told the report that state and federal lawmakers still need to address PBM underpayment and increase reimbursement-rate transparency. Dominguez said some states, including Ohio and California, use a flat-fee PBM model that pays pharmacies a fixed, transparent fee per claim, and she said a similar approach could work in Texas.

Dominguez said, “I think most people just want transparency,” adding that if everyone is paid the same, competition would shift toward service. At the same time, Texas 2036’s Charles Miller said supporters of PBM overhauls should be careful about placing blame on any single company or person, arguing instead that the outcome reflects broader system rules. “Ultimately, we need to look at the rules that we have designed around PBMs, and if we don’t like how they’re behaving, it’s probably because we set up a poor system,” Miller said.

While pharmacists and advocates press for policy changes, Tilton and McEntire said they plan to keep trying to maintain their businesses through diversification. Tilton said she plans to retire in about nine years, and McEntire said she has considered closing a second pharmacy in Shamrock but added that doing so would burden her employees and their paychecks. Both owners acknowledged that shifting business conditions—such as new development—could bring additional competitive pressure, even as they work to keep pharmacies stocked and staffed so residents can obtain medication locally.

The Texas Tribune report also noted that in 2023, 60% of Texas counties did not have a pharmacy, and in 2025, more than 4.3 million Texans lived in pharmacy deserts, while one pharmacy closes each week in Texas according to the Texas Pharmacy Association.