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.

Cardiology - Lodoco PA Policy	Policy
Cardiology - Myqorzo PA with Step Therapy Policy	Policy
Cardiology - Ranolazine Products Step Therapy Policy	Policy
Cardiology - Tryvio PA Policy	Policy
Cardiology - Verquvo DQM Policy - Per Rx	Policy
Cardiology - Zontivity PA Policy	Policy
Chelating Agents - Chemet PA Policy	Policy
Chelating Agents - Penicillamine Products PA with Step Therapy Policy	Policy
Chelating Agents - Trientine Products PA Policy	Policy
Chelating Agents – Iron Chelators (Oral) PSM Policy	Policy
Chenodiol Products PA Policy	Policy
Cholbam PA Policy	Policy
Chorionic Gonadotropins DQM Policy - Per Rx	Policy
Chorionic Gonadotropins PSM Policy	Policy
Cinacalcet PA	Policy
Colchicine Products Preferred Step Therapy Policy	Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for Flex, High Performance, and National Preferred Formularies	Policy
Colony Stimulating Factors - Leukine PA Policy	Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy	Policy
Colony Stimulating Factors - Pegfilgrastim Products, Rolvedon and Ryzneuta PSM Policy For Flex, High Performance, and National Preferred Formularies	Policy
Complement Inhibitors - Eculizumab Products PA Policy	Policy
Complement Inhibitors - Empaveli PA Policy	Policy
Complement Inhibitors - Fabhalta PA Policy	Policy
Complement Inhibitors - PiaSky PA Policy	Policy
Complement Inhibitors - Ultomiris PA Policy	Policy
Complement Inhibitors - Veopoz PA Policy	Policy
Complement Inhibitors - Voydeya PA Policy	Policy
Complement Inhibitors - Zilbrysq PA Policy	Policy
Complement System Disorders - WHIM Syndrome - Xolremdi PA Policy	Policy
Coronavirus – Oral Medications for Treatment of COVID-19 DQM Policy – Per Days	Policy
Coronavirus Disease - Evusheld PA Policy	Policy
Coronavirus Disease - Veklury PA Policy	Policy
Corticosteroids (Intraarticular) - Zilretta PA Policy	Policy
Corticosteroids (Nasal) - Mometasone DQM Policy - Per Rx	Policy
Corticosteroids (Nebulized) - Budesonide DQM Policy - Per Rx	Policy
Crysvita PA Policy	Policy
Cushing's - Isturisa PA Policy	Policy
Cushing's - Mifepristone PA Policy	Policy
Cushing's - Mifepristone PSM Policy	Policy
Cushing's - Recorlev PA Policy	Policy
Cushing's - Signifor PA Policy	Policy
Cushing's Disease - Isturisa DQM Policy - Per Rx	Policy
Cystic Fibrosis - Bronchitol PA Policy	Policy
Cystic Fibrosis - Pulmozyme PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Alyftrek PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Kalydeco PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Orkambi PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Symdeko PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Trikafta DQM Policy - Per Rx	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Trikafta PA Policy	Policy
Dermatology - Anzupgo DQM Policy - Per Days	Policy
Dermatology - Anzupgo PA Policy	Policy
Dermatology - Filsuvez PA Policy	Policy
Dermatology - Gene Therapy - Vyjuvek PA Policy	Policy
Dermatology - Hyftor PA	Policy
Dermatology - Opzelura PA Policy	Policy
Dermatology - Vtama DQM Policy - Per Days	Policy
Dermatology - Zoryve DQM Policy - Per Days	Policy
Desmopressin Products - Nocdurna PA Policy	Policy
Diabetes - Canagliflozin Products DQM Policy - Per Rx	Policy
Diabetes - CeQur Products DQM Policy - Per Days	Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy	Policy
Diabetes - Dexcom Sensors DQM Policy - Per Days	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy	Policy
Diabetes - Freestyle Libre Sensors DQM Policy - Per Days	Policy
Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy	Policy
Diabetes - Guardian Sensors DQM Policy - Per Days	Policy
Diabetes - Metformin Extended-Release DQM Policy - Per Rx	Policy
Diabetes - Metformin Step Therapy Policy	Policy
Diabetes - Omnipod Pods DQM Policy - Per Days	Policy
Diabetes - Simplera Sensors DQM Policy - Per Days	Policy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy	Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy	Policy
Diabetes - Symlin PA Policy	Policy
Diabetes - twiist Products DQM Policy - Per Days	Policy
Diabetes - Tzield PA Policy	Policy
Diabetes - V-Go Products DQM Policy - Per Days	Policy
Dichlorphenamide PSM Policy	Policy
Diuretic - Enbumyst PA with Step Therapy Policy	Policy
Diuretics - Loop Products Step Therapy Policy	Policy
Diuretics – Hydrochlorothiazide Step Therapy Policy	Policy
Dronabinol Products PA with Step Therapy Policy	Policy
Droxidopa PA Policy	Policy
Enspryng PA Policy	Policy
Enzyme Replacement Therapy - Aldurazyme PA Policy	Policy
Enzyme Replacement Therapy - Avlayah PA Policy	Policy
Enzyme Replacement Therapy - Elaprase PA Policy	Policy
Enzyme Replacement Therapy - Elfabrio PA Policy	Policy
Enzyme Replacement Therapy - Fabrazyme PA Policy	Policy
Enzyme Replacement Therapy - Kanuma PA Policy	Policy
Enzyme Replacement Therapy - Lamzede PA Policy	Policy
Enzyme Replacement Therapy - Loargys PA Policy	Policy
Enzyme Replacement Therapy - Mepsevii PA Policy	Policy
Enzyme Replacement Therapy - Naglazyme PA Policy	Policy
Enzyme Replacement Therapy - Revcovi PA Policy	Policy
Enzyme Replacement Therapy - Strensiq PA Policy	Policy
Enzyme Replacement Therapy - Sucraid PA Policy	Policy
Enzyme Replacement Therapy - Vimizim PA Policy	Policy
Enzyme Replacement Therapy - Xenpozyme PA Policy	Policy
Epinephrine Auto-Injectors Step Therapy Policy	Policy

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