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.

Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy	Policy
Allergen Immunotherapy - Odactra PA Policy	Policy
Allergen Immunotherapy - Palforzia DQM Policy - Per Rx	Policy
Allergen Immunotherapy - Palforzia PA Policy	Policy
Allergen Immunotherapy - Ragwitek PA Policy	Policy
Alpha-Adrenergic Blockers - Doxazosin DQM Policy - Per Rx	Policy
Alpha-Adrenergic Blockers - Terazosin DQM Policy - Per Rx	Policy
Alpha1-Proteinase Inhibitor Products PA Policy	Policy
Amifampridine Products PA Policy	Policy
Amyloidosis - Onpattro PA Policy	Policy
Amyloidosis - Tegsedi PA Policy	Policy
Amyloidosis - Wainua PA Policy	Policy
Amyloidosis Products for Cardiomyopathy PSM policy	Policy
Angiotensin Receptor Blocker Step Therapy Policy	Policy
Anti-Influenza DQM Policy - Per Days	Policy
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy	Policy
Antibiotics - Vancomycin Capsules PA Policy	Policy
Antibiotics - Xifaxan PA Policy	Policy
Antibiotics (Inhaled) - Arikayce PA Policy	Policy
Antibiotics (Inhaled) - Cayston PA Policy	Policy
Antibiotics (Inhaled) - Tobramycin Products PSM Policy	Policy
Antibiotics (Injectable) PA Policy	Policy
Antidepressants - Bupropion Long-Acting DQM Policy - Per Rx	Policy
Antidepressants - Raldesy Step Therapy Policy	Policy
Antidepressants - Selective Serotonin Reuptake Inhibitors DQM Policy - Per Rx	Policy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors DQM Policy - Per Rx	Policy
Antidepressants Step Therapy Policy	Policy
Antiemetics - Doxylamine and Pyridoxine Combination Products DQM Policy - Per Rx and Per Days	Policy
Antiemetics - Serotonin Receptor Antagonists (Oral and Transdermal) DQM Policy - Per Rx	Policy
Antiemetics - Substance P-Neurokinin-1 Receptor Antagonists (Oral) DQM Policy - Per Rx	Policy
Antifungals - Cresemba (Oral) PA Policy	Policy
Antifungals - Fluconazole (Oral) DQM Policy - Per Rx	Policy
Antifungals - Flucytosine PA Policy	Policy
Antifungals - Itraconazole DQM Policy - Per Rx	Policy
Antifungals - Posaconazole (Oral) PA Policy	Policy
Antifungals - Tolsura PA with Step Therapy Policy	Policy
Antifungals - Vivjoa PA Policy	Policy
Antifungals - Voriconazole (Oral) PA Policy	Policy
Antifungals (Azoles) - Intravenous Products PA Policy	Policy
Antifungals for Vulvovaginal Candidiasis Step Therapy Policy	Policy
Antiplatelets - Ticagrelor Step Therapy Policy	Policy
Antiseizure Medications - Clobazam Products PA Policy	Policy
Antiseizure Medications - Diacomit PA Policy	Policy
Antiseizure Medications - Divalproex Sodium, Valproic Acid Step Therapy Policy	Policy
Antiseizure Medications - Epidiolex PA Policy	Policy
Antiseizure Medications - Fintepla PA Policy	Policy
Antiseizure Medications - Lacosamide Step Therapy Policy	Policy
Antiseizure Medications - Lamotrigine Step Therapy Policy	Policy
Antiseizure Medications - Levetiracetam, Brivaracetam Step Therapy Policy	Policy
Antiseizure Medications - Nayzilam PA Policy	Policy
Antiseizure Medications - Oxcarbazepine Step Therapy Policy	Policy
Antiseizure Medications - Rufinamide PA Policy	Policy
Antiseizure Medications - Topiramate Step Therapy Policy	Policy
Antiseizure Medications - Valtoco PA Policy	Policy
Antiseizure Medications - Vigabatrin DQM Policy - Per Rx	Policy
Antiseizure Medications - Vigabatrin PA Policy	Policy
Antiseizure Medications - Xcopri DQM Policy - Per Rx	Policy
Antiseizure Medications - Zonisamide Step Therapy Policy	Policy
Antiseizure Medications - Ztalmy PA Policy	Policy
Antivirals - Famciclovir DQM Policy - Per Rx	Policy
Antivirals - Ribavirin (Inhaled Products) PA Policy	Policy
Antivirals - Ribavirin (Oral Products) PA Policy	Policy
Antivirals - Valacyclovir DQM Policy - Per Rx	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications Step Therapy Policy	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy	Policy
Barth Syndrome - Forzinity PA Policy	Policy
Benign Prostatic Hyperplasia - 5-Alpha-Reductase Inhibitors Step Therapy Policy	Policy
Benign Prostatic Hyperplasia - Alpha Blockers Step Therapy Policy	Policy
Benign Prostatic Hyperplasia - Terazosin Step Therapy Policy	Policy
Benign Prostatic Hyperplasia – Entadfi PA Policy	Policy
Beta Blocker Step Therapy Policy	Policy
Bile Acid Sequestrants Step Therapy Policy	Policy
Bisphosphonates (Oral) Enhanced Step Therapy Policy	Policy
Bone Modifiers - Denosumab (Prolia) PSM Policy	Policy
Bone Modifiers - Denosumab (Xgeva) PSM Policy	Policy
Bone Modifiers - Denosumab Products (Xgeva) DQM Policy - Per Rx	Policy
Bone Modifiers - Evenity PA Policy	Policy
Bone Modifiers - Ibandronate Intravenous PA Policy	Policy
Bone Modifiers - Teriparatide Products PA Policy	Policy
Bone Modifiers - Tymlos PA Policy	Policy
Bone Modifiers - Zoledronic Acid (Reclast) PA Policy	Policy
Botulinum Toxin Products PSM Policy	Policy
Botulinum Toxins - Dysport PA Policy	Policy
Botulinum Toxins - Myobloc PA Policy	Policy
Bowel Agents - Lubiprostone DQM Policy - Per Rx	Policy
Bowel Agents - Opioid-Induced Constipation Preferred Step Therapy Policy	Policy
Bruton's Tyrosine Kinase Inhibitor - Rhapsido PA Policy	Policy
Cabergoline DQM Policy - Per Days	Policy
Calcitonin Gene-Related Peptide Inhibitors - Aimovig DQM Policy - Per Days	Policy
Carbinoxamine Step Therapy Policy	Policy
Cardiology - Cardamyst PA Policy	Policy
Cardiology - Ivabradine PA Policy	Policy
Cardiology - Lodoco PA Policy	Policy
Cardiology - Ranolazine Products Step Therapy Policy	Policy
Cardiology - Tryvio PA Policy	Policy
Cardiology - Verquvo DQM Policy - Per Rx	Policy
Chelating Agents - Chemet PA Policy	Policy
Chelating Agents - Penicillamine Products PA with Step Therapy Policy	Policy

Back to top