On Nov. 1, 2019, UnitedHealthcare introduced the new Cancer Therapy Pathways Program to promote the use of evidence-based and cost-effective regimens. Starting January 2020, we’re excited to offer you the opportunity to earn rewards through our Cancer Therapy Pathways Program. Rewards will only be available for eligible UnitedHealthcare commercial plans.
How the Program Will Work
The Cancer Therapy Pathway regimens are selected on the basis of clinical benefit (efficacy) and side-effect profile (toxicity). Among regimens with comparable efficacy and toxicity, additional consideration is given to the frequency of hospitalizations during treatment, duration of therapy, drug costs and total cost of care.
The program will be available for most common cancer types and will include options for defined biomarker subsets and lines of therapy. However, given the complexity of cancer, we don’t expect to have a pathway for every medical condition.
Cancer Therapy Pathways are not a substitute for the experience and judgment of a physician or other health care professional. Any clinician participating in the program must use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. Care decisions are between the physician and the patient. We do not make decisions about the kind of care that should or should not be received.
The Cancer Therapy Pathways are available through Optum’s Cancer Guidance Program, which is accessed through Link when submitting an authorization request for any UnitedHealthcare commercial plans (excluding UnitedHealthcare Oxford commercial plans), UnitedHealthcare affiliate health plans, UnitedHealthcare Community Plan and UnitedHealthcare Medicare Advantage Plan members.
Participation in the program is voluntary and the selection of a pathway regimen is not required to receive prior authorization for therapy. UnitedHealthcare’s criteria for cancer therapy coverage determinations will not change as a result of this program.
Where allowed under state law, care providers will have the opportunity to receive rewards through a financial incentive based on pathway adherence. To be eligible for a reward, pathway adherence must be 75% or greater at the practice level during the performance measurement period, which is a six-month period of time. Additional criteria and exclusions may apply.
You are eligible to participate in the program and earn rewards if you meet the following guidelines:
- You’re submitting prior authorization requests for chemotherapy or related therapies through Optum’s Cancer Guidance Program.
- You’re in-network for your patient’s benefit plan.
- Your patient is part of a UnitedHealthcare commercial plan that is eligible for rewards. 1
Care providers who are out-of-network for their patient’s plan are eligible to use the Cancer Therapy Pathways, but are not eligible to earn rewards.
Health Plans Included
Members in an UnitedHealthcare commercial plan, which currently requires prior authorization for chemotherapy and related cancer therapies, are eligible for rewards with the exception of the following health plans:2
- UnitedHealthcare commercial plans identified as Indemnity/Options PPO
- UnitedHealthcare Oxford commercial plans
- Affiliate health plans such as Golden Rule Insurance Company and All Savers Insurance Company
Pathway Data Dashboard
A dashboard will be available to view pathway adherence, which is expected in late spring 2020. Information on when the dashboard will be available for viewing, how to access the Pathways Data Dashboard and a schedule of available training sessions is forthcoming.
- Cancer Therapy Pathways – Frequently Asked Questions
- Cancer Therapy Pathways Program and Rewards – Frequently Asked Questions
- Cancer Therapy Pathways Program – Pathway Regimens
If you have questions, please email firstname.lastname@example.org.
DISCLAIMER: UnitedHealthcare reserves the right to change, cancel or modify the program and its features, including reward eligibility, at any time and to temporarily suspend the program at any time without prior notice.
If there is any suspected fraud or abuse, UnitedHealthcare reserves the right to stop or discontinue reward payment(s).
1 Eligibility varies by health plan and state and is subject to all applicable laws and regulations.
2 This is not an exhaustive list and is subject to change. Eligibility varies by health plan and state and is subject to all applicable laws and regulations.
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