At the Healthcare Advocate Summit, Prerak Parikh shared Prime’s strategic approach to utilization management, IRA implications, and the future of specialty pharmacy – with data-driven insights. 

During the “Navigating the Impact: Payer Perspectives, IRA Challenges, and the Future of Specialty Pharmacy” panel at the Healthcare Advocate Summit in Las Vegas, Prerak Parikh, PharmD, director, specialty clinical solutions for Prime Therapeutics (Prime), delivered a compelling overview of how payers are evolving their strategies to ensure safe and effective specialty drug use. 

Parikh emphasized the scientific rigor behind Prime’s clinical policy development, which draws from U.S. Food and Drug Administration (FDA) labeling, peer-reviewed literature, Centers for Medicare & Medicaid Services (CMS) guidance, and National Comprehensive Cancer Network (NCCN) criteria. He highlighted the role of key opinion leaders and advisory boards – especially in oncology – in shaping and vetting policies. “Every policy goes through our Pharmacy and Therapeutics (P&T) Committee and is regularly updated to reflect new guidelines, label expansions, and dosage changes,” Parikh noted. 

On the topic of the Inflation Reduction Act (IRA), Parikh explained that while the medical benefit side has seen minimal direct impact so far, changes are on the horizon. He pointed to upcoming CMS drug price negotiations for Part D drugs, effective January 2026, and predicted improved access and reduced out-of-pocket costs for Medicare beneficiaries. He also noted that inflation-based rebates have already led to lower coinsurance rates for some Part B drugs, which traditionally carry a 20% coinsurance. 

Parikh addressed the growing prevalence of high-cost gene and cell therapies, noting that over 40 such therapies have been approved, most costing over $1 million per treatment. He further added that it is crucial for health plans to have a prior authorization process where each patient's clinical consideration is evaluated individually to help ensure proper access from a clinical and safety perspective. 

To reduce administrative burden for provider-based access teams, Parikh outlined Prime’s efforts to streamline prior authorization processes. These include a web-based PA platform with real-time updates, embedded drug policies, and peer-to-peer consultations with specialty-matched physicians. “There is immense value when our specialist physician has a conversation with the ordering provider and both can come together to forge the best path forward for the patient,” Parikh said. 

Looking ahead, he encouraged industry and access professionals to collaborate on non-traditional utilization management strategies such as dose optimization and site of care shifts and prioritize member education to drive biosimilar adoption.