What is the Quality Care Cancer Program?

The Quality Care Cancer Program is a utilization management program that requires providers to request prior authorization for therapeutic and supportive medical oncology drugs on behalf of Blue Cross Blue Shield of Massachusetts’ (Blue Cross) 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 Blue Cross medical policy, you’ll know whether the service is covered or not.

• S-code reimbursement (applies to medical oncology services only):

  By choosing Carelon Cancer Treatment Pathways regimens when clinically appropriate, in-network Blue Cross ordering physicians may be eligible for additional reimbursement. Out-of-network health care providers or out-of-area BlueCard providers are not eligible for S-code reimbursement.