Mandatory Drug Wastage Program Enhancement

EmblemHealth is implementing a Mandatory Drug Wastage (MDW) Program through Prime Therapeutics, our pharmacy benefit manager. This is a policy-driven initiative to reduce medication waste and promote appropriate dosing of select provider-administered drugs.

Key updates providers should know:

• The targeted drug list will expand from 46 to 150 medications.
• During prior authorization (PA) review, providers may be prompted to round doses down to the nearest vial size when clinically appropriate.
• If a provider declines a drug wastage opportunity, the request will be pended for clinical review, and medical necessity documentation may be required.
• Providers may request an exception when a lower dose is not clinically appropriate. Examples include situations where a reduced dose previously resulted in suboptimal outcomes. Peer-to-peer review remains available when needed.
• The program applies to commercial and Medicaid lines of business, City of New York HMO plans, and NY State of Health marketplace plans.
• Due to Centers for Medicare and Medicaid Services requirements, participation remains voluntary for Medicare members; however, the Medicare voluntary drug list will align with the expanded enhanced program drug list.

For both new and renewal authorization requests involving drugs included in the program, providers will be asked to either accept the recommended dose optimization opportunity or provide a clinical rationale supporting an exception.

Enhanced Oncology Value (EOV) Program

EmblemHealth is also implementing an Enhanced Oncology Value (EOV) Program through Prime Therapeutics to support evidence-based oncology care and encourage the use of treatment regimens that provide the best balance of safety, efficacy, and value.

Key updates providers should know:

• Prior authorization requirements for select oncology drugs will incorporate criteria that may be more stringent than Food and Drug Administration (FDA) labeling and National Comprehensive Cancer Network (NCCN) recommendations when supported by clinical evidence.
• Certain non-FDA-approved indications, including some NCCN-supported uses, may be excluded when available published evidence does not demonstrate sufficient clinical benefit.
• When multiple treatment options offer comparable efficacy, preferred regimens may be recommended based on safety profiles, lower toxicity, and cost-effectiveness. Preferred regimens maintain NCCN ratings that are equal to the requested therapy.
• Patients currently receiving treatment or with an existing authorization will continue to be reviewed under renewal criteria and will not be subject to new-start EOV requirements.
• The program applies to commercial and Medicaid lines of business, City of New York HMO plans, and NY State of Health marketplace plans.
• Medicare is excluded from the EOV Program.

For new treatment starts involving drugs included in the program, providers may be required to submit additional clinical information to support requests that fall outside preferred treatment pathways. Existing members receiving ongoing therapy will continue to be evaluated under established renewal criteria.