Tech-Enabled Flexibility Reshaping Pharmacy Benefits Landscape

The pharmacy benefits industry is undergoing a significant transformation as organizations seek greater control, transparency, and adaptability in managing their pharmacy benefit programs. A shift towards modular, unbundled models is gaining traction, driven by rising drug costs, increased regulatory pressure, and evolving consumer expectations.

Traditional PBM Models Face Scrutiny

For decades, the industry relied on bundled pharmacy benefit management (PBM) contracts that promised efficiency through scale. Large PBMs offered end-to-end services, managing benefits such as claims adjudication and rebate contracting under a single agreement. However, this one-size-fits-all approach is now being reconsidered.

A recent survey by Pharmacy Strategies Group (PSG) found that nearly one in three organizations are evaluating unbundled PBM models. These modular frameworks allow plan sponsors to separate individual services and choose specialized partners based on performance, value, and strategic fit.

John Zevzavadjian, President of Enterprise Solutions at RxSense, emphasized the importance of transparency: "We all want to understand where every dollar is being spent through the supply chain. Ultimately, it's the consumer and the plan who benefit from the lowest net cost. But if there are inefficiencies, like spread pricing or markups, it's the consumer and the payer who end up footing the bill."

Technology Driving the Shift to Modular Models

Legacy PBM platforms, built to handle volume and scale, are increasingly seen as barriers to innovation. As organizations seek to modernize the member experience and align pharmacy benefits with broader health strategies, the need for more flexible, technology-driven solutions has become apparent.

RxSense, a technology company in the pharmacy benefits space, is addressing this challenge with a fully integrated, end-to-end platform that provides real-time visibility across claims adjudication, plan design, and analytics. Built on a unified and modern code base, the platform eliminates the need for bolt-on solutions and ensures seamless data flow across all services.

"Real-time information is critical for health plans, large employers, and PBMs to make clinical, financial, or operational decisions," said Zevzavadjian. RxSense's modular platform includes essential touchpoints such as prior authorization and clinical program integration, using API-based architecture to enable near real-time data exchange with third-party vendors.

Industry Leaders Embracing Change

In 2023, Blue Shield of California made headlines with its decision to unbundle PBM services and redesign its model. This move has demonstrated to the industry what's possible when traditional PBM services are unbundled, allowing payers to mix and match partners to create a more flexible and tailored benefit experience that meets the needs of their members.

As more organizations seek flexibility and control, companies like RxSense are offering not just the technology but also the strategic support to make modular transformation achievable. Whether clients choose to unbundle all at once or take a phased approach, cross-functional teams of engineers, product leaders, and industry experts are available to guide implementation and long-term success.

The pharmacy benefits industry is clearly shifting away from standardization and moving toward greater customization. An increasing number of health plans, employers, health systems, and third-party administrators are adopting models that offer vendor flexibility, deeper data insights, and the ability to adapt quickly to changing market demands. While bundled models may continue to work for some, the broader direction is becoming clear: the future of pharmacy benefits is built on transparency, adaptability, and modern infrastructure.