What is the Medical Oncology Program?

The Medical Oncology Program is a utilization management program that requires providers to request prior authorization for therapeutic and supportive medical oncology drugs on behalf of members. The goal is to cover clinically efficacious, safe, and cost-effective treatment with the fewest side effects. Importantly, the Program also supports oncology practices in significant ways:

• Actionable information:
  When your practice prescribes a cancer treatment regimen for a patient and submits it to Carelon Medical Benefits Management for review, the prescribed regimen is compared against evidence-based Carelon Cancer Treatment Pathways (Pathways). If the planned regimen is not aligned with a Pathway, information on available Pathway regimens may be presented for your review.

• Getting a coverage decision before the service is rendered:
  Because the services requested are reviewed in real-time against health plan medical policy or LCD/NCDs, you’ll know whether the service is covered or not. Most health plans use NCCN 2a or 2b criteria as medical policy.

• S-code reimbursement (dependent on health plan participation):
  Most clients provide practices with enhanced reimbursement for utilizing Pathway regimens. By choosing Carelon Cancer Treatment Pathways regimens when clinically appropriate, ordering physicians may be eligible for additional reimbursement.