WASHINGTON, D.C.—Specialty pharmacy is a key cost driver for employers and insurers, with development in this space showing no signs of slowing down.
For example, a recent study from the Pharmaceutical Strategies Group found that 43% of employers and benefit leaders view managing specialty pharmacy spend as a top goal. And, per that report, while specialty drugs generally make up about half of the development pipeline, 76% of novel new drugs approved by the Food and Drug Administration in 2025 were specialty products.
It's with that backdrop that Blues-backed pharmacy benefit manager Prime Therapeutics convened stakeholders from across the pharmaceutical supply chain for its annual Specialty Summit last month. One of the prevailing themes of the conference—a need to break down siloes between the pharmacy benefit and medical benefit to more effectively manage the full patient care journey.
Mostafa Kamal, CEO of Prime, told Fierce Healthcare in an interview that patients don't necessarily experience a complex condition through the lens of separate medical and pharmacy benefits, so their care experience should reflect that.
He noted that given the complexity of the therapies in the specialty category and the conditions managed with these treatments, about half of specialty pharmacy spend sits in the medical benefit.
"We believe if you're not managing specialty in an integrated way, you're not really managing specialty," Kamal said.
One of the ways Prime is bridging those gaps, he said, is through the acquisition of Magellan Rx, which closed in 2022. That deal served as a foundation for the push to better unite the medical and pharmacy benefit, and Prime has invested in initiatives in that arena in the years since the deal closed.
Another key piece to the puzzle, he said, is the company's shared ownership structure. The PBM is jointly owned by 19 Blue Cross Blue Shield plans.
Making a new approach to specialty pharmacy work also requires companies like Prime to take a new approach to how they think about their role, said George Van Antwerp, senior vice president of product innovation and strategy at Prime, in an interview.
During a session at the conference, he described it as a shift from viewing the specialty pharmacy as a dispensary, and instead as a critical piece of the broader care coordination ecosystem. Part of how the team is able to make that change at Prime gets back to the incentives in place through its financial model.
Prime's economic model isn't tied to fulfillment, he said, allowing it to identify the most efficient models without that pressure. For example, a program launched by the PBM called IntegratedRx allows patients to fill certain prescriptions at an in-house pharmacy or at their doctor's office.
In doing so, the provider and pharmacist are in direct communication, and that supports care coordination more effectively.
IntegratedRx covers medications for cystic fibrosis and oncology. Through the program, Prime has found a 9% reduction in the total cost of care, and that 95% of patients were either satisfied or very satisfied with their experience.
If a certain pharmacy or fulfillment option is "right, cost-effective, clinically appropriate," Prime can adapt to that because the company isn't incentivized to fill the drug itself, Van Antwerp said.
Stephen Cutts, chief clinical and specialty officer at Prime, told Fierce that there's also a significant financial opportunity in finding ways to rethink the patient's journey. About 3% of patients drive approximately 60% of spending in the pharmacy benefit, and if the medical benefit is included, then between 10% and 13% of patients are driving more than 90% of total drug costs.
"You're talking about an increasingly concentrated group of patients that are driving a disproportionate amount of drug spend, and there's an incredible amount of complexity that's needed in order to be able to deliver a more personalized care experience for those patients," Cutts said.
For instance, a patient may start with a therapy that's administered in the hospital setting and then want to switch to an option they can administer themselves at home. Managing that transition requires a picture of both the medical and pharmacy sides.
Having the existing relationship with multiple BCBS plans undergirds this work too, he said, as the PBM can tap into their medical benefits data in managing the patients' needs.
"We're more of an orchestrator that is able to help make sure that the patient can get that needed medication at the right site of care that's more convenient and cost-effective," Cutts said. "I would say that this is a huge opportunity, not just today but increasingly in the future."