Tap into our Expert Clinical Network

Gain insights from leading key opinion leaders (KOLs) to drive better care. 

Better care & consultation for complex diseases 

Our Expert Clinical Network (ECN) is part of our value-based approach to medical and pharmacy benefit management. Prime customers have access to 175+ national and world-renowned key opinion leaders (KOLs) in multiple disease categories. These KOLs help clients with challenging prior authorization case reviews, peer-to-peer discussions, drug policy development and formulary guidance. Our ECN supports health plans and providers to make more informed decisions, leading to positive member outcomes and mitigating inappropriate care. 

Access to specialized experts & insights 

Our ECN is comprised of 175+ unaffiliated, specialty-matched physician KOLs who have expertise in a wide range of conditions and drugs spanning the medical and pharmacy benefit. These independent experts are affiliated with leading medical institutions across the United States, including Mayo Clinic, Memorial Sloan Kettering, Johns Hopkins and other major centers nationwide. 

Tailored expertise & informed, people-centric solutions 

Access our network of leading experts who provide customized evidence-based recommendations to address your unique challenges and priorities. Through the lens of real-world clinical expertise, our specialists offer tailored, literature-supported guidance for prior authorization case reviews, peer-to-peer discussions and drug policies that align with your organizational goals and support effective, efficient member care. 

Comprehensive disease coverage 

Our network covers a wide range of disease categories, ensuring specialized guidance regardless of the clinical area. We take a targeted approach to managing complex, high-cost conditions, particularly in areas such as oncology, hematology and neurology. Our experts provide in-depth knowledge and support for advanced treatments, including gene therapy, CAR T-cell therapies and drugs for rare diseases. Whether a member is navigating the intricacies of oncology, managing a neurological disorder or exploring autoimmune category management, our network of field-leading experts is here to help.  

Real-world solutions

Request

Prime received a request for a nonformulary biologic in a young patient with severe Crohn’s disease, as the provider documented past failures of a biologic on the formulary.

Response

We determined failure of the previous biologic was due to nonadherence. The member’s labs did not suggest resistance to anti-tumor necrosis factor (TNF) therapy. The KOL recommended a new trial of the anti-TNF therapy at appropriate dose.  

Request

Prime received a request for intravenous immunoglobulin (IVIG) as a maintenance treatment for myasthenia gravis. This use is not approved under the health plan’s guidelines. The member, who was on pyridostigmine and prednisone at the time, was stable and did not show signs of worsening symptoms. The prescriber aimed to use IVIG to manage symptoms and gradually taper off prednisone.  

Response

After a peer-to-peer discussion, the KOL provided evidence-based recommendations. It was noted that most neurologists would use a combination of prednisone and azathioprine, which typically allows for a gradual reduction of prednisone, effectively controls myasthenia and is generally safe. 

Request

A health plan partnered with us to implement enhanced prior authorization (PA) reviews of medical benefit drugs, with a focus on high-cost therapies for rare diseases. As part of our utilization management program for high-cost therapies, a specialty-matched physician completed a review of a PA request.  

Response

The oncology specialist’s recommendation to deny was upheld after peer-to-peer consultation. The specialist knew this patient was not a candidate for CAR-T treatment (only one line of therapy for FL). During the peer-to-peer discussion, the specialist presented clinical trial data, leading the ordering provider to confirm that, for this specific member with chemotherapy-refractory FL, the standard of care would be an alternative combination therapy. 

Footnotes

*All brand names are property of their respective owners.
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