The Blue Cross NC Medical Oncology Program promotes optimal support for our members' cancer care needs, while reducing the costs for managing one of the most complex, expensive and prevalent diseases they can encounter. (Effective April 1, 2017)
This program includes online access to support tools for selecting cancer treatment regimens, consistent with current evidence and consensus guidelines for oncologists and hematologists. The program includes Carelon Cancer Treatment Pathways (Pathways) based on medical evidence and best practices developed with leading cancer experts.
Pathway regimens are widely accepted as a key component to managing oncology quality and cost. Carelon Cancer Treatment Pathways offer support in identifying highly effective therapies that are often more affordable for our members. More specific than guidelines, they identify treatments based on clinical efficacy, favorable toxicity profiles and cost.
Pathway regimens in this program are informed by a clinical library and include evidence drawn from:
- Peer-reviewed published literature
- Expert consensus statements and guidelines from professional organizations, including:
- American Society of Clinical Oncology (ASCO)
- American Society of Hematology (ASH)
- National Comprehensive Cancer Network (NCCN)
- Federal government agencies, including:
- Food and Drug Administration (FDA)
- National Cancer Institute (NCI)
The program, administered by Carelon Medical Benefits Management, will help improve cancer care quality for eligible Blue Cross NC members, and manage the associated costs for certain complex tests and treatments by promoting patient care that's appropriate, safe and affordable.
The Carelon portal opened March 20, 2017, for prior review requests. Requests can be made for treatments planned to begin on or after the April 1, 2017 date of service.
Requesting Prior Approval for Medical Oncology
The prior review code list requires prior authorization through the Carelon Provider Portal or by phone at 866-455-8414 Monday through Friday, 8 a.m. to 6 p.m. ET. The list is updated on a quarterly basis, in the first 10 days of January, April, July and October. If there is no update within this time period, the list will remain unchanged until the following quarter.
Unlisted and miscellaneous health services codes should only be used if a specific code hasn't been established by the American Medical Association.
Pharmacy Benefit Programs
Drugs requiring prior authorization/precertification under the member's pharmacy benefits
Blue Cross NC Utilization Management program information, including which medications require review and how to submit requests electronically, is available online. Note: Prior review of pharmacy benefit drugs is performed according to the member's benefit plan, not by Carelon.
Effective April 1, 2017, in addition to the medical benefit drugs that will require prior review through the Carelon Medical Oncology Program, several oral oncology drugs on the pharmacy benefit will be added to the Blue Cross NC utilization management program.
The program will ensure that medications are used according to evidence-based guidelines per compendia and prescribing information from the FDA. The program looks for pertinent diagnoses, dosing/quantity limits and bio-marker tests where applicable. Learn More
Medicare Part D members
According to our Medicare Part D formularies, most oral oncology drugs require prior review. Please be advised that these medications will require prior approval for members with Medicare prescription drug benefits. Learn More
Medical Oncology Program update
The Medical Oncology Program applies to outpatient and professional medical oncology services only. Inpatient prior authorizations for medical oncology drugs will be handled by the Blue Cross NC utilization management per the current process. Learn More
- Coordination of Benefits (COB)
Carelon Provider Portal in Blue e
To obtain prior review, always enter the Carelon Provider Portal in Blue e, regardless of Blue Cross NC COB carrier status (primary, secondary or tertiary).
Medical Oncology Program resources
Get more information on the program, worksheets, an interactive tutorial and other helpful tools on Carelon's Blue Cross NC provider page.
You can find a comprehensive list of oncology drugs included in the Carelon Medical Oncology Program (Program) within our Prior Review (Prior Plan Approval) Code List.
Information on our individual medical policies for oncology drugs included in the Program can be found by searching the appropriate drug name within our Categorical Index section listed under our Medical Guidelines.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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