This program was launched April 1, 2017, to support our members' cancer care needs, while reducing the costs of managing one of the most expensive and common diseases a member may face.
The Medical Oncology Program offers support tools for cancer treatment regimens and online access for:
- Oncologists (specializing in cancer prevention, diagnosis and treatment)
- Urologists (specializing in diseases of the urinary tract and male reproductive system), and
- Hematologists (specializing in diseases of the blood)
The program includes Cancer Treatment Pathways based on medical evidence and best practices developed with leading cancer experts. Pathways offer support in finding highly effective therapies that may be more affordable for members.
Pathway treatments are widely accepted as vital to managing oncology quality and costs. More specific than guidelines, Pathway treatments are selected based on clinical effectiveness, favorable toxicity profiles and cost. Cancer Treatment Pathways are based on a detailed review of effectiveness, harmfulness, and cost informed by a clinical library and include evidence drawn from:
- 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)
See Guidelines for Site of Care (Place of Service for Medical Infusions Policy)
The Medical Oncology Program is provided by Carelon Medical Benefits Management. Carelon helps improve cancer care quality for eligible Blue Cross NC members, as well as manage the 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.
See a full list of oncology drugs included in the Carelon Medical Oncology Program in our Prior Review (Prior Plan Approval) Code List here.
Providers Requesting Prior Approval for Medical Oncology Services
Carelon ProviderPortal in Blue e | Prior Plan Approval: Commercial/Medicare
The prior review code list requires prior authorization through the Carelon ProviderPortalSM or by phone at 1-866-455-8414 Monday - Friday, 8 a.m. - 6 p.m. EST.
The list is updated, in the first 10 days of January, April, July and October. If no update is made in the first 10 days, 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.