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 - Odactra PA Policy-1 | Policy |
| Allergen Immunotherapy - Odactra PA Policy-2 | Policy |
| Allergen Immunotherapy - Palforzia DQM Policy - Per Rx-1 | Policy |
| Allergen Immunotherapy - Palforzia PA Policy-1 | Policy |
| Allergen Immunotherapy - Palforzia PA Policy-2 | Policy |
| Allergen Immunotherapy - Palforzia PA Policy-3 | Policy |
| Allergen Immunotherapy - Ragwitek PA Policy-1 | Policy |
| Allergen Immunotherapy - Ragwitek PA Policy-2 | Policy |
| Alpha-Adrenergic Blockers - Doxazosin DQM Policy - Per Rx-1 | Policy |
| Alpha-Adrenergic Blockers - Terazosin DQM Policy - Per Rx-1 | Policy |
| Alpha1-Proteinase Inhibitor Products PA Policy-1 | Policy |
| Alzheimer's Disease Step Therapy Policy-1 | Policy |
| Alzheimer's Disease Step Therapy Policy-2 | Policy |
| Amifampridine Products PA Policy-1 | Policy |
| Amyloidosis - Amvuttra PA Policy-1 | Policy |
| Amyloidosis - Onpattro PA Policy-1 | Policy |
| Amyloidosis - Tafamidis Products PA Policy-1 | Policy |
| Amyloidosis - Tegsedi PA Policy-1 | Policy |
| Angiotensin Receptor Blocker Step Therapy Policy-1 | Policy |
| Angiotensin Receptor Blocker Step Therapy Policy-2 | Policy |
| Anti-Influenza - Relenza DQM Policy - Per Rx | Policy |
| Anti-Influenza DQM Policy - Per Days | Policy |
| Antibiotics - Linezolid (Zyvox), Sivextro PA Policy-1 | Policy |
| Antibiotics - Linezolid (Zyvox), Sivextro PA Policy-2 | Policy |
| Antibiotics - Xifaxan PA Policy-1 | Policy |
| Antibiotics (Inhaled) - Arikayce PA Policy-1 | Policy |
| Antibiotics (Inhaled) - Cayston PA Policy-1 | Policy |
| Antibiotics (Inhaled) - TOBI Podhaler PA Policy-1 | Policy |
| Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA Policy-1 | Policy |
| Antibiotics (Inhaled) - Tobramycin Products PSM Policy-1 | Policy |
| Antibiotics (Injectable) PA Policy-1 | Policy |
| Anticoagulants - Dabigatran PA Policy-1 | Policy |
| Anticoagulants - Dabigatran PA Policy-2 | Policy |
| Anticoagulants - Eliquis PA Policy-1 | Policy |
| Anticoagulants - Eliquis PA Policy-2 | Policy |
| Anticoagulants - Savaysa PA Policy-1 | Policy |
| Anticoagulants - Savaysa PA Policy-2 | Policy |
| Anticoagulants - Xarelto PA Policy-1 | Policy |
| Anticoagulants - Xarelto PA Policy-2 | Policy |
| Anticoagulants - Xarelto PA Policy-3 | Policy |
| Anticoagulants - Xarelto PA with Step Therapy Policy-1 | Policy |
| Antidepressants - Bupropion Long-Acting DQM Policy - Per Rx-1 | Policy |
| Antidepressants - Selective Serotonin Reuptake Inhibitors DQM Policy - Per Rx | Policy |
| Antidepressants - Selective Serotonin Reuptake Inhibitors DQM Policy - Per Rx-1 | Policy |
| Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors DQM Policy - Per Rx | 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 - Serotonin Receptor Antagonists (Oral and Transdermal) DQM Policy - Per Rx-1 | Policy |
| Antiemetics - Substance P-Neurokinin-1 Receptor Antagonists (Oral) DQM Policy - Per Rx | Policy |
| Antiemetics - Substance P-Neurokinin-1 Receptor Antagonists (Oral) DQM Policy - Per Rx-1 | Policy |
| Antiemetics - Substance P-Neurokinin-1 Receptor Antagonists (Oral) DQM Policy - Per Rx-2 | Policy |
| Antifungals - Cresemba (Oral) PA Policy | Policy |
| Antifungals - Cresemba (Oral) PA Policy-1 | Policy |
| Antifungals - Fluconazole (Oral) DQM Policy - Per Rx | Policy |
| Antifungals - Itraconazole DQM Policy - Per Rx | Policy |
| Antifungals - Posaconazole (Oral) PA Policy | Policy |
| Antifungals - Posaconazole (Oral) PA Policy-1 | Policy |
| Antifungals - Vivjoa PA Policy | Policy |
| Antifungals - Voriconazole (Oral) PA Policy | Policy |
| Antifungals - Voriconazole (Oral) PA Policy-1 | Policy |
| Antifungals - Voriconazole (Oral) PA with Step Therapy Policy | Policy |
| Antifungals (Azoles) - Intravenous Products PA Policy | Policy |
| Antifungals for Vulvovaginal Candidiasis 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 - Divalproex Sodium, Valproic Acid Step Therapy Policy-1 | Policy |
| Antiseizure Medications - Epidiolex PA Policy | Policy |
| Antiseizure Medications - Fintepla PA Policy | Policy |
| Antiseizure Medications - Lacosamide 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 - Topiramate Step Therapy Policy-1 | Policy |
| Antiseizure Medications - Topiramate Step Therapy Policy-2 | Policy |
| Antiseizure Medications - Valtoco PA Policy | Policy |
| Antiseizure Medications - Vigabatrin PA Policy | Policy |
| Antiseizure Medications - Ztalmy PA Policy | Policy |
| Antiseizure Medications - Ztalmy PA Policy-1 | 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 PA Policy-1 | Policy |
| Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy | Policy |
| Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy-1 | Policy |
| Benign Prostatic Hyperplasia - Alpha Blockers Step Therapy Policy | Policy |
| Benzodiazepines - Diazepam (Oral) DQM Policy - Per Days | Policy |
| Benzodiazepines DQM Policy for InMynd - Per Rx | Policy |
| Beta Blocker Step Therapy Policy | Policy |
| Beta Blocker Step Therapy Policy-1 | Policy |
| Beta Blocker Step Therapy Policy-2 | Policy |
| Bile Acid Sequestrants Step Therapy Policy | Policy |
| Bisphosphonates (Oral) Enhanced Step Therapy Policy | Policy |
| Bisphosphonates (Oral) Step Therapy Policy | Policy |