Medical pharmacy is becoming a larger share of health care spending as new treatments and care approaches emerge. Health plans need timely, actionable insights to understand what is coming, assess the clinical evidence on new therapies and prepare to support patients as these therapies become available. 

Gaining these insights is the first step. When clinical benefit and financial decisions work together, payers can help patients get the appropriate treatment more easily while helping manage total cost of care. Prime’s health plan-aligned model is designed so its success moves in the same direction as the success of its clients and members — supporting decisions based on patient needs, clinical value and affordability.

“New therapies continue to reshape the healthcare landscape, creating both opportunities and challenges for health plans,” said Kristen Reimers, RPh, senior vice president of specialty clinical solutions at Prime Therapeutics (Prime). “Trend insights help payers look beyond individual therapies and understand how changes across the market may affect patients’ treatment and care. That broader view helps health plans align clinical and financial decisions, and support better outcomes and greater affordability for patients.”

More people are living with cancer — and treatment is evolving

The American Cancer Society estimates that more than 22 million people will be living with a history of cancer by 2035. This growth will increase demand across benefits and reinforce why incentives and decisions must be aligned around patient value. Connected medical and pharmacy data can give payers a more complete view of treatment, helping care teams coordinate decisions, identify gaps and manage outcomes and total cost of care together. For patients, that alignment can mean more connected care and fewer barriers between a treatment decision and access to medication.

Prime uses a holistic approach so health plans, pharmacists, providers and care teams can work from the same information and toward the same goals. Because Prime’s model is not built around directing utilization to owned pharmacy assets, it takes a patient-centric approach that helps plans and care teams select the setting and support model that best fits the patient. One example is the IntegratedRx^® program, which aligns incentives by connecting pharmacy care with a patient’s physicians while preserving choice and supporting local care. Since the program’s inception, it has delivered more than $150 million in savings and a 9% reduction in total medical costs for patients with cancer.

Cell and gene therapies are testing traditional payment models

There are more than 2,200 cell and gene therapies in the development pipeline globally, according to the American Society of Gene and Cell Therapy. These treatments could transform care for people with rare and serious conditions. However, their high initial price and unanswered questions about how long their benefits last can make coverage, access and financial planning difficult.

Use and spending are already increasing. Recent data shows a 30% rise in cell and gene therapy use by members from 2022 through 2025. In Prime’s 2026 survey of 57 health plans representing 246 million covered lives, 79% said financial impact was their top concern. Use and spending are already increasing. As use grows, payers and manufacturers are exploring payment models that can help distribute costs over time while keeping clinical value, affordability and patient access at the center. Expertise and insights into specialty can help inform those discussions by giving health plans a clearer view of emerging therapies, expected utilization and potential financial impact.

Costs are rising across every line of business

Specialty drug trends reinforce the need for early pipeline visibility, strong clinical management and an integrated view of medical and pharmacy claims. When these capabilities are aligned around patient value, health plans can anticipate impacts, act earlier and make decisions that support clinical quality, access and affordability together.

Turning trend data into action

Prime’s 2026 Medical Pharmacy Trend Report combines payer perspectives with medical benefit drug data to examine payer strategies, drug trends and forecasts across commercial, Medicare and Medicaid plans. These findings help health plans connect clinical insight, benefit strategy and patient support around patient value so better care, simpler experiences and affordability can move forward together.