When asked if the pizza should be cut in six or eight slices, a customer said: “Six slices. I don’t think I can eat eight.” The response seems funny because we assume the total is the same — but in practice, it’s not. Anyone who has sliced a pizza knows that each cut leaves traces of cheese, sauce, or crust on the cutting board. The more cuts you make, the more you lose.
Medication systems work similarly. Every time patients obtain drugs outside their drug plan’s network, another cut appears in their medication history. With each cut, clinical visibility is lost. Layering direct-to-consumer (DTC) channels multiplies these blind spots.
Risks of fragmented medication histories
When patients bypass prescription drug plans, critical safety checks disappear. MCOs and PBMs routinely screen for drug–drug interactions, contraindications, duplicate therapy flags — but these safeguards work properly only when the complete medication history can be seen. Without this unified view, prescribers might unknowingly prescribe a medication that previously did not work or caused an allergic reaction, or pharmacists might miss a dangerous interaction between an off-plan generic and a covered specialty drug.
This information loss also weakens disease management and medication therapy management programs. PBMs use integrated pharmacy and medical claims to identify when diabetes patients stop filling metformin, when heart failure patients skip ACE inhibitors, or when cancer patients struggle with expensive specialty medications. The programs can then engage prescribers and provide patient education. When fills occur off-plan, this early warning system fails. A patient might appear nonadherent to their covered medications when they’ve actually switched to a cash-pay alternative, leading to unnecessary interventions or missed opportunities for support.
Fragmentation happens when patients use pharmacies outside their drug plan’s network. Layering direct-to-consumer (DTC) channels multiplies the blind spots, because no single party sees the whole list in real time.
Cash-pay generics: Data lost at the counter
Walmart’s low-cost generic program, launched in October 2006, offers 20 generic drugs — including heart-pressure medications, lipid-lowering therapies, antibiotics, and thyroid drugs — at $4 for a 30-day supply or $10 for 90 days. The program includes 75 additional drugs, including metformin, at $9 for 30 days or $24 for 90 days.
Because a $10 copay for a Tier 1 generic is common in many commercial and Medicare plans, patients often save money by paying cash instead of using their insurance. While this benefits some patients financially, it creates dangerous blind spots for MCOs and PBMs that lose visibility into these fills, potentially leading to duplicated prescriptions, missed interactions, or gaps in understanding the patient’s medication regimen.
Alternative funding programs: Risks of going off-benefit
Alternative funding programs (AFPs) emerged in the mid-2010s as a strategy to reduce plan spending on high-cost specialty drugs. The first widely cited program, SaveOnSP, was founded in 2015. Under AFP arrangements, certain high-cost specialty drugs are designated as “non-covered.” Patients prescribed those drugs are routed to a third-party administrator (TPA), which then applies for the manufacturer’s patient assistance programs on the patient’s behalf, claiming they have “no coverage.”
While AFPs lower plan spending, they create significant blind spots. When a specialty drug claim is rejected and routed to a third-party administrator for manufacturer assistance, the health plan’s visibility ends. Plans know a patient attempted to start the medication, but they don’t know if the patient actually received it, whether the patient is taking it consistently, or why the patient might have stopped.
Fortunately, these arrangements affect only a subset of high-cost specialty drugs, not the majority of prescriptions, so their fragmentation impact is somewhat limited. Like other cash-pay or manufacturer-direct channels, AFPs trade budget relief for greater risk in safety and oversight.
Tech platforms and new blind spots
Walmart’s cash-pay model was just the beginning. Additional disruption came when tech giants entered the pharmacy space.
Amazon Pharmacy. Launched in November 2020, Amazon Pharmacy offers multiple programs beyond simple mail order: RxPass provides Amazon Prime members unlimited access to more than 50 common generic medications for $5 per month. While it is available in most states, it is limited to a small set of drugs. Because RxPass operates outside traditional drug plans, PBMs and MCOs remain blind to these fills. Prime Rx offers prescription discounts at nearly 60,000 pharmacies nationwide — including major chains like CVS, Walgreens, Rite Aid, Costco, Safeway, and Amazon Pharmacy itself.
Amazon positions Prime Rx as a tool to use when an insurance copay is higher than the Prime price, when a medication isn’t covered, when deductibles are higher than the Prime price, or when the patient has no insurance. But patients don’t always heed that guidance. The result: some fills shift outside of drug plan records, creating gaps in the data PBMs and MCOs rely on.
Mark Cuban Cost Plus Drug Company (MCCPDC). Founded in January 2022, MCCPDC sells thousands of generic medications online at transparent prices (cost + 15% markup + fee + shipping).
The fragmentation risks with MCCPDC are heightened because it operates primarily as a cash-pay channel outside traditional insurance systems. Most major insurance plans are not yet integrated with the platform, forcing most customers to pay out of pocket and seek reimbursement separately — if at all. While the company focuses mainly on generic drugs with limited branded products and no controlled substances, this does not eliminate safety concerns. Generic medications can still cause dangerous interaction that neither system would catch when fills are split across platforms. For example, patients might fill a blood thinner through MCCPDC and an anti-inflammatory through their regular pharmacy, creating bleeding risks that no single system would flag.
Manufacturer portals: direct channels, fractured records
Manufacturers have launched direct-to-consumer portals that serve as alternate pathways for patients:
- In September 2020, AbbVie introduced Synthroid Delivers, a cash-pay program administered by Eagle Pharmacy, provides brand-name Synthroid at fixed per-prescription prices with free home delivery, outside of insurance and PBM networks
- LillyDirect, launched in January 2024, connects patients to Lilly medications for obesity, migraine, and diabetes through third-party pharmacies with both insurance-based and self-pay delivery options
- NovoCare Pharmacy, launched in March 2025, offers uninsured or underinsured patients cash-pay access to Wegovy at $499 per month with free home delivery, fulfilled through third-party pharmacy partners
These programs can be lifelines for the uninsured, underinsured, those on limited income or those whose plans don’t cover certain branded drugs. But they introduce new, disconnected channels for fills — potentially invisible to the regular medical record.
On May 12, 2025, President Trump signed an executive order, “Delivering Most-Favored-Nation Prescription Drug Pricing to American Patients.” It directs the Health and Human Services secretary to facilitate direct-to-consumer purchasing programs where manufacturers sell products at the most-favored-nation price, aligning U.S. prices with the lowest available in other developed countries. This explicit policy nudged manufacturers to explore direct channels as a way to deliver lower prices to patients — but those channels further fragment the medication history unless integrated responsibly.
However, the fragmentation risk from manufacturer channels may be more limited in scope than other direct-pay options. They are typically confined to single branded products rather than broad therapeutic categories, so the blind spots they create are real but not systemwide. Manufacturers typically launch these programs only for specific high-cost branded medications where they see potential to expand market access — usually for drugs with significant uninsured populations or formulary coverage gaps.
The missing pieces for MCOs and PBMs
Patients now have more ways to access prescriptions at lower prices — through Walmart’s low-cost generic program, Amazon Pharmacy, MCCPDC, and manufacturer portals. These programs appeal directly to patients seeking convenience and cost savings. But every time a prescription bypasses the benefit system, it leaves MCOs and PBMs with an incomplete record of what medications a patient is taking, and that undermines their ability to coordinate safety alerts, manage formularies, and oversee utilization across patient populations.
Walmart’s low-cost generic program, alternative funding programs, tech-driven pharmacies, and now manufacturer portals — some more disruptive than others — all contribute to the same problem: eroding visibility. For MCOs and PBMs, every fill that falls outside the benefit system is another cut in the record: an interaction not checked, an adherence gap not flagged, a therapy history not fully captured. Just as a pizza loses a little with every slice, the medication record loses pieces of the story each time a channel bypasses the plan. Those missing pieces matter.
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