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Starting Jan. 1, 2027, Accredo Specialty Pharmacy will not be a participating specialty pharmacy for practitioner-administered medical drugs. 

You will be required to order practitioner-administered specialty drugs directly from a new specialty pharmacy.

Please see the attached list that shows the specialty drug orders that are currently referred to Accredo Specialty Pharmacy, the J-Codes, and the required new specialty pharmacy. Active, open prescriptions currently serviced by Accredo will be transitioned to the new vendor.

If you have questions, please sign in to emblemhealth.com/providers and use our Live Agent Chat  or Message Center to contact us. A provider customer service representative will be happy to help. 

As announced in News & Updates on Oct. 19, 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 & 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.

EmblemHealth is 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.

View the full list of Pharmacy Medical Policies. 

New York City employees, non-Medicare retirees, and their dependents are offered the New York City Employees PPO (NYCE PPO) plan, a health plan delivered through a partnership between EmblemHealth and UnitedHealthcare. 

To help you and your practice become familiar with NYCE PPO, we’ve created a webinar, New York City Employees PPO Plan: What Providers Need To Know, that highlights some of the most important features of this new plan so you can work with us as you care for plan members.

We also encourage you to visit nyceppo.com, home to all things NYCE PPO.  

If you need help navigating our provider portals, please see our videos and quick guides and Frequently Asked Questions pages. 

If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.

We recommend that you take advantage of the training opportunities offered by CMS’ Medicare Learning Network and eMedNY. 

Audit Insights: High-Risk Diagnosis Coding. A focused review of prostate cancer, pressure ulcers and acute stroke. Watch our training video. 

You may view other online learning opportunities on our provider website.