Utilization Management

Prescription Drug Prior Authorization and Step Therapy Policies for Cascade Select Marketplace Business

Not all medications will be covered on the formulary. Non-formulary medications are subject to the Medical Necessity for Non-Formulary Medications policy. Please consult the formulary to verify coverage.

Erythropoiesis-Stimulating Agents PSM Policy De-Identified	Policy
Estrogens (Topical) - Estradiol Gel DQM Policy - Per Rx De-Identified	Policy
Estrogens (Topical) - Patches DQM Policy - Per Days De-Identified	Policy
Ezetimibe Step Therapy Policy De-Identified	Policy
Fabry Disease - Galafold PA Policy De-Identified	Policy
Fenofibrate Preferred Step Therapy Policy De-Identified	Policy
Fenofibrate Step Therapy Policy De-Identified	Policy
Gabapentin Step Therapy Policy De-Identified	Policy
Gamifant PA Policy De-Identified	Policy
Gastroenterology - Gattex PA Policy De-Identified	Policy
Gaucher Disease - Enzyme Replacement Therapy - Cerezyme PA Policy De-Identified	Policy
Gaucher Disease - Enzyme Replacement Therapy - Elelyso PA Policy De-Identified	Policy
Gaucher Disease - Enzyme Replacement Therapy - Vpriv PA Policy De-Identified	Policy
Gaucher Disease - Enzyme Replacement Therapy PSM Policy De-Identified	Policy
Gaucher Disease - Substrate Reduction Therapy - Cerdelga PA Policy De-Identified	Policy
Gaucher Disease - Substrate Reduction Therapy - Miglustat PA Policy De-Identified	Policy
Gaucher Disease - Substrate Reduction Therapy PSM Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Agonists - Implants PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Antagonists - Myfembree PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa DQM Policy - Per Days De-Identified	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy De-Identified	Policy
Gout - Krystexxa PA Policy De-Identified	Policy
Gout Medications Step Therapy Policy De-Identified	Policy
Growth Disorders - Growth Hormone (Daily) PSM Policy De-Identified	Policy
Growth Disorders - Growth Hormone PA Policy De-Identified	Policy
Growth Disorders - Increlex PA Policy De-Identified	Policy
Growth Disorders - Skytrofa PA Policy De-Identified	Policy
Growth Disorders - Voxzogo PA Policy De-Identified	Policy
Helicobacter Pylori Infection Combination Products Preferred Step Therapy Policy De-Identified	Policy
Hematology - Cablivi PA Policy De-Identified	Policy
Hematology - Ceprotin PA Policy De-Identified	Policy
Hematology - Coagadex PA Policy De-Identified	Policy
Hematology - Corifact PA Policy De-Identified	Policy
Hematology - Enjaymo PA Policy De-Identified	Policy
Hematology - Fibrinogen Products PA Policy De-Identified	Policy
Hematology - Gene Therapy - Zynteglo PA Policy De-Identified	Policy
Hematology - Pyrukynd DQM Policy - Per Days De-Identified	Policy
Hematology - Pyrukynd PA Policy De-Identified	Policy
Hematology - Reblozyl PA Policy De-Identified	Policy
Hematology - Ryplazim PA Policy De-Identified	Policy
Hematology - Tretten PA Policy De-Identified	Policy
Hematology - Vonvendi PA Policy De-Identified	Policy
Hemophilia - Eptacog Products - NovoSeven RT PA Policy De-Identified	Policy
Hemophilia - Eptacog Products - Sevenfact PA Policy De-Identified	Policy
Hemophilia - Factor IX Products PA Policy De-Identified	Policy
Hemophilia - Factor VIII Products PA Policy De-Identified	Policy
Hemophilia - FEIBA PA Policy De-Identified	Policy
Hemophilia - Hemlibra PA Policy De-Identified	Policy
Hemophilia - Recombinant Factor VIII Products PSM Policy De-Identified	Policy
Hepatitis C - Epclusa DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Epclusa PA Policy De-Identified	Policy
Hepatitis C - Harvoni DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Harvoni PA Policy De-Identified	Policy
Hepatitis C - Mavyret DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Mavyret PA for PSM Policy De-Identified	Policy
Hepatitis C - Mavyret PA Policy De-Identified	Policy
Hepatitis C - Sovaldi DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Sovaldi PA Policy De-Identified	Policy
Hepatitis C - Viekira Pak DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Viekira Pak PA Policy De-Identified	Policy
Hepatitis C - Vosevi PA Policy De-Identified	Policy
Hepatitis C - Zepatier PA Policy De-Identified	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for High Performance Formulary De-Identified	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred FLEX Formulary De-Identified	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred Formulary and Basic Formulary De-Identified	Policy
Hepatology - Bylvay DQM Policy - Per Rx De-Identified	Policy
Hepatology - Givlaari PA Policy De-Identified	Policy
Hepatology - Livmarli PA Policy De-Identified	Policy
Hepatology - Ocaliva PA Policy De-Identified	Policy
Hepatology – Bylvay PA Policy De-Identified	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy De-Identified	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PSM Policy De-Identified	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy De-Identified	Policy
Hereditary Angioedema - Icatibant PA Policy De-Identified	Policy
Hereditary Angioedema - Icatibant PSM Policy De-Identified	Policy
Hereditary Angioedema - Kalbitor PA Policy De-Identified	Policy
Hereditary Angioedema - Orladeyo PA Policy De-Identified	Policy
Hereditary Angioedema - Takhzyro PA Policy De-Identified	Policy
Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy De-Identified	Policy
Homozygous Familial Hypercholesterolemia - Juxtapid PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Apretude PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Cabenuva DQM Policy - Per Days De-Identified	Policy
Human Immunodeficiency Virus - Cabenuva PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Complera PSM Policy (Basic Formulary) De-Identified	Policy
Human Immunodeficiency Virus - Prezcobix PSM Policy (Basic Formulary) De-Identified	Policy
Human Immunodeficiency Virus - Rukobia PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Stribild PSM Policy (Basic Formulary) De-Identified	Policy
Human Immunodeficiency Virus - Sunlenca PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Trogarzo PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Truvada PSM Policy De-Identified	Policy
Hyaluronic Acid Derivatives Intraarticular PA Policy De-Identified	Policy
Hyaluronic Acid Derivatives Intraarticular PSM Policy De-Identified	Policy
Hydrocortisone Acetate Suppository Step Therapy Policy De-Identified	Policy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors DQM Policy - Per Rx De-Identified	Policy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors Step Therapy Policy De-Identified	Policy
Hyperlipidemia - Nexletol PA Policy De-Identified	Policy
Hyperlipidemia - Nexlizet PA Policy De-Identified	Policy