Across the country, health systems are rethinking their reliance on legacy PBMs. Instead of outsourcing, more organizations are bringing PBM functions in-house to take back control, capture savings, and create new revenue streams.
This move toward PBM insourcing puts organizations in the driver’s seat, giving them greater flexibility and clearer visibility into how pharmacy dollars are spent. What once felt out of reach is now becoming the norm. With the combination of RxSense’s advanced technology and deep operational and clinical expertise, health systems can scale faster, modernize their infrastructure, and rely on a trusted partner to guide strategy and execution.
5 questions health systems ask RxSense about PBM insourcing
As more organizations explore PBM insourcing, the conversation turns from why to how. Health systems want to know what it really takes to get started, what resources they will need, and how much control they can expect to have.
Here are some of the most common questions we hear and how RxSense helps answer them:
- How many claims do we need to get started?
A good benchmark is about 100,000 annual claims, which works out to roughly 10,000 covered lives. Many mid-sized health systems already meet or exceed this number, making insourcing a realistic option.
- Do we need to add staff?
In many cases, no. Many organizations manage their PBM function with existing teams by assigning a central point of contact and spreading responsibilities across roles. RxSense also offers expert support when you need it, but always on your terms.
- How much control will we have?
You own your pharmacy benefit strategy. RxSense provides the tools and infrastructure, but you decide how your PBM runs, including network configurations, performance targets, and pricing strategies.
- What are the benefits of insourcing our PBM?
The benefits can be both strategic and financial. For some health plans and health systems, insourcing offers:
- Generate new revenue streams through selling your PBM to local markets and leverage your internal dispensing channels
- Improved margin capture through internal pharmacy channels
- Better visibility into pricing, operations, and performance data
- Consultative control of your pharmacy program with greater flexibility in plan design and formulary management
- How do we manage the program post-launch?
Our technology includes built-in PBM business management, growth, and performance tools so you can monitor financial performance, manage contracts, optimize networks, and identify new opportunities all in one platform.
Driving growth through partnership: RxSense helped increase a health system’s in-house claims by 130%
A leading health system with 65,000 employees and dependents was looking for a partner to help them build and operate their own PBM, with direct access to an intuitive adjudication and benefits platform. Their goal was to fully leverage internal pharmacy assets such as dispensing channels and 340B purchasing, while relying on a partner they could trust operationally, clinically, and strategically.
With RxSense as their partner, the health system launched its PBM in just a few months using RxIQ® Enterprise, gaining greater control and flexibility. By leveraging internal and specialty pharmacies, contracting directly for rebate management, and using RxSense’s network and specialty wrap services, they optimized prescription volume, savings, and revenue across dispensing channels and 340B strategies. They also expanded their capabilities to administer PBM programs for local employers, driving additional traffic into in-house pharmacies and creating a long-term engine for growth.
As a result of partnering with RxSense, the health system achieved the following pre and post shift to in-house pharmacy utilization:
- R90 medications share increased 363%
- Specialty medications share increased 164%
- In-house claims increased 130%
The new era of PBM insourcing
PBM insourcing is no longer out of reach. What once required big infrastructure, long timelines, and large teams can now be achieved faster, more efficiently, and with fewer resources through modern, cloud-based technology like RxIQ Enterprise. RxIQ Enterprise gives health systems the flexibility, transparency, and control to capture savings, strengthen member trust, and align pharmacy benefits with their mission.
The bottom line: PBM insourcing is now within reach, and RxSense is ready to help you make it possible.
Ready to take control of your pharmacy benefits? Contact us today to schedule a demo and see what RxIQ Enterprise can do for your organization.
