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.

Oncology - Xalkori DQM Policy - Per Rx De-Identified	Policy
Oncology - Xalkori PA Policy De-Identified	Policy
Oncology - Xermelo DQM Policy - Per Rx De-Identified	Policy
Oncology - Xermelo PA Policy De-Identified	Policy
Oncology - Xospata PA Policy De-Identified	Policy
Oncology - Xpovio PA Policy De-Identified	Policy
Oncology - Xtandi DQM Policy - Per Rx De-Identified	Policy
Oncology - Xtandi PA Policy De-Identified	Policy
Oncology - Yonsa PA Policy De-Identified	Policy
Oncology - Zejula PA Policy De-Identified	Policy
Oncology - Zelboraf PA Policy De-Identified	Policy
Oncology - Zolinza PA Policy De-Identified	Policy
Oncology - Zydelig PA Policy De-Identified	Policy
Oncology - Zykadia PA Policy De-Identified	Policy
Ophthalmic - Glaucoma - Alpha-Adrenergic Agonists Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Beta-adrenergic Blockers Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Combination Products Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Prostaglandins PA Policy De-Identified	Policy
Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy De-Identified	Policy
Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy De-Identified	Policy
Ophthalmic Corticosteroids Step Therapy Policy De-Identified	Policy
Ophthalmic Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy De-Identified	Policy
Ophthalmology - Dry Eye Disease - Cyclosporine Products PA Policy De-Identified	Policy
Ophthalmology - Dry Eye Disease - Eysuvis PA Policy De-Identified	Policy
Ophthalmology - Dry Eye Disease - Lacrisert DQM Policy - Per Rx De-Identified	Policy
Ophthalmology - Dry Eye Disease - Lacrisert PA Policy De-Identified	Policy
Ophthalmology - Dry Eye Disease - Xiidra PA Policy De-Identified	Policy
Ophthalmology - Durysta PA Policy De-Identified	Policy
Ophthalmology - Luxturna PA Policy De-Identified	Policy
Ophthalmology - Tepezza PA Policy De-Identified	Policy
Ophthalmology - Upneeq PA Policy De-Identified	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu PA De-Identified	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Eylea PA De-Identified	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Ranibizumab Products PA De-Identified	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA De-Identified	Policy
Ophthalmology - Verkazia PA Policy De-Identified	Policy
Ophthalmology – Oxervate PA Policy De-Identified	Policy
Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Vabysmo PA Policy De-Identified	Policy
Opioids - Butorphanol DQM Policy - Per Days De-Identified	Policy
Opioids - Fentanyl Transdermal Products DQM Policy - Per Days De-Identified	Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy De-Identified	Policy
Opioids - Fentanyl Transmucosal Products DQM Policy - Per Days De-Identified	Policy
Opioids - Long-Acting Products (Oral) DQM - Per Days De-Identified	Policy
Opioids - Long-Acting Products PA Policy De-Identified	Policy
Opioids - Morphine Milligram Equivalent (200) DQM Policy De-Identified	Policy
Opioids - Morphine Milligram Equivalent (90) DQM Policy De-Identified	Policy
Opioids - Nucynta DQM Policy - Per Rx De-Identified	Policy
Opioids - Short-Acting Products DQM Policy (Adults) - Per Rx De-Identified	Policy
Opioids - Short-Acting Products DQM Policy (All Ages) - Per Rx De-Identified	Policy
Opioids - Short-Acting Products DQM Policy (Pediatrics) - Per Rx De-Identified	Policy
Opioids - Tramadol Extended-Release Products DQM Policy - Per Rx De-Identified	Policy
Overactive Bladder Medications Preferred Step Therapy Policy De-Identified	Policy
Overactive Bladder Medications Step Therapy Policy De-Identified	Policy
Parkinson's Disease - Kynmobi PA Policy De-Identified	Policy
Parkinson's Disease - Monoamine Oxidase Type B Inhibitors Step Therapy Policy De-Identified	Policy
Parkinson's Disease - Ongentys PA Policy De-Identified	Policy
Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy Policy De-Identified	Policy
Parkinson’s Disease - Apokyn PA Policy De-Identified	Policy
Parkinson’s Disease - Carbidopa PA Policy De-Identified	Policy
Parkinson’s Disease - Duopa PA Policy De-Identified	Policy
Parkinson’s Disease - Inbrija PA Policy De-Identified	Policy
Parkinson’s Disease - Nourianz PA Policy De-Identified	Policy
Parkinson’s Disease - Nuplazid PA Policy De-Identified	Policy
Parkinson’s Disease - Tolcapone PA Policy De-Identified	Policy
Phenylketonuria - Palynziq DQM Policy - Per Rx De-Identified	Policy
Phenylketonuria - Palynziq PA Policy De-Identified	Policy
Phenylketonuria - Sapropterin PA Policy De-Identified	Policy
Phosphate Binders DQM Policy - Per Rx De-Identified	Policy
Potassium Binders - Lokelma DQM Policy - Per Rx De-Identified	Policy
Potassium Binders - Veltassa DQM Policy - Per Rx De-Identified	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy De-Identified	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy De-Identified	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Repatha DQM Policy - Per Days De-Identified	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Related Products - Leqvio PA Policy De-Identified	Policy
Proton Pump Inhibitors DQM Policy - Per Rx De-Identified	Policy
Proton Pump Inhibitors Step Therapy Policy De-Identified	Policy
Psychiatry - Novel Psychotropics DQM Policy - Per Rx De-Identified	Policy
Psychiatry - Spravato PA Policy De-Identified	Policy
Psychiatry - Zulresso PA Policy De-Identified	Policy
Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy De-Identified	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers DQM Policy - Per Rx De-Identified	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy De-Identified	Policy
Pulmonary - Roflumilast PA with Step Therapy Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Adempas DQM Policy - Per Rx De-Identified	Policy
Pulmonary Arterial Hypertension - Adempas PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PSM Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Orenitram DQM Policy - Per Rx De-Identified	Policy
Pulmonary Arterial Hypertension - Orenitram PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Treprostinil Injection PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Treprostinil Injection PSM Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PSM Policy De-Identified	Policy
Qbrexza PA Policy De-Identified	Policy
Repository Corticotropin - Acthar Gel PA Policy De-Identified	Policy