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 (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Lorbrena PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Lorbrena PA Policy-1 | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Xalkori - Per Rx | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Xalkori PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Zykadia PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Zykadia PA Policy-1 | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Zykadia PA Policy-2 | Policy |
| Oncology (Oral - Androgen Biosynthesis Inhibitor) - Abiraterone Acetate DQM Policy - Per Rx | Policy |
| Oncology (Oral - Androgen Biosynthesis Inhibitor) - Abiraterone Acetate PA Policy | Policy |
| Oncology (Oral - Androgen Biosynthesis Inhibitor) - Abiraterone Acetate PA Policy-1 | Policy |
| Oncology (Oral - Androgen Biosynthesis Inhibitor) - Yonsa PA Policy | Policy |
| Oncology (Oral - Androgen Biosynthesis Inhibitor) - Yonsa PA Policy-1 | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Erleada PA Policy | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Nubeqa PA Policy | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Nubeqa PA Policy-1 | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Xtandi DQM Policy - Per Rx | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Xtandi DQM Policy - Per Rx-1 | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Xtandi PA Policy | Policy |
| Oncology (Oral - BRAF Inhibitor) - Braftovi PA Policy | Policy |
| Oncology (Oral - BRAF Inhibitor) - Braftovi PA Policy-1 | Policy |
| Oncology (Oral - BRAF Inhibitor) - Tafinlar PA Policy | Policy |
| Oncology (Oral - BRAF Inhibitor) - Tafinlar PA Policy-1 | Policy |
| Oncology (Oral - BRAF Inhibitor) - Tafinlar PA Policy-2 | Policy |
| Oncology (Oral - BRAF Inhibitor) - Zelboraf PA Policy | Policy |
| Oncology (Oral - BRAF Inhibitor) - Zelboraf PA Policy-1 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Brukinsa PA Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Brukinsa PA Policy-1 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Brukinsa PA Policy-2 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Calquence DQM Policy - Per Rx | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Calquence PA Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Calquence PA Policy-1 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Calquence PA Policy-2 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Imbruvica PA Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Imbruvica PA Policy-1 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Imbruvica PA Policy-2 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Jaypirca PA Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Jaypirca PA Policy-1 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Jaypirca PA Policy-2 | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Jaypirca PA Policy-3 | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Ibrance PA Policy | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Ibrance PA Policy-1 | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Ibrance PA Policy-2 | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Kisqali and Kisqali Femara Co-Pack PA Policy | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Verzenio PA Policy | Policy |
| Oncology (Oral - EGFR Inhibitor) - Erlotinib PA Policy | Policy |
| Oncology (Oral - EGFR Inhibitor) - Gefitinib PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Erlotinib PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gefitinib PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gefitinib PA Policy-1 | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gilotrif PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gilotrif PA Policy-1 | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Lazcluze PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Lazcluze PA Policy-1 | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Tagrisso PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Vizimpro PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Vizimpro PA Policy-1 | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Lytgobi PA Policy | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Lytgobi PA Policy-1 | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Pemazyre PA Policy | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Pemazyre PA Policy-1 | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Rydapt PA Policy | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Xospata PA Policy | Policy |
| Oncology (Oral - Hedgehog Pathway Inhibitor) - Erivedge PA Policy | Policy |
| Oncology (Oral - Hedgehog Pathway Inhibitor) - Odomzo PA Policy | Policy |
| Oncology (Oral - Immunomodulator) - Lenalidomide PA Policy | Policy |
| Oncology (Oral - Immunomodulator) - Lenalidomide PA Policy-1 | Policy |
| Oncology (Oral - Immunomodulator) - Pomalyst PA Policy | Policy |
| Oncology (Oral - Immunomodulator) - Pomalyst PA Policy-1 | Policy |
| Oncology (Oral - Immunomodulator) - Thalomid PA Policy | Policy |
| Oncology (Oral - Immunomodulator) - Thalomid PA Policy-1 | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Rezlidhia PA Policy | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Tibsovo PA Policy | Policy |
| Oncology (Oral - Kirsten RAt Sarcoma Virus Inhibitor) - Krazati PA Policy | Policy |
| Oncology (Oral - Kirsten RAt Sarcoma Virus Inhibitor) - Krazati PA Policy-1 | Policy |
| Oncology (Oral - Kirsten RAt Sarcoma Virus Inhibitor) - Lumakras PA Policy | Policy |
| Oncology (Oral - Kirsten RAt Sarcoma Virus Inhibitor) - Lumakras PA Policy-1 | Policy |
| Oncology (Oral - MEK Inhibitor) - Cotellic PA Policy | Policy |
| Oncology (Oral - MEK Inhibitor) - Cotellic PA Policy-1 | Policy |
| Oncology (Oral - MEK Inhibitor) - Mekinist PA Policy | Policy |
| Oncology (Oral - MEK Inhibitor) - Mekinist PA Policy-1 | Policy |
| Oncology (Oral - MEK Inhibitor) - Mektovi PA Policy | Policy |
| Oncology (Oral - MEK Inhibitor) - Mektovi PA Policy-1 | Policy |
| Oncology (Oral - Mesenchymal-Epithelial Transition Skipping Agent) - Tabrecta PA Policy | Policy |
| Oncology (Oral - Mesenchymal-Epithelial Transition Skipping Agent) - Tepmetko PA Policy | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Rozlytrek PA Policy | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Rozlytrek PA Policy-1 | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Vitrakvi PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Lynparza PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Rubraca PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Rubraca PA Policy-1 | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Talzenna PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Zejula PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Zejula PA Policy-1 | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Zejula PA Policy-2 | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Zejula PA Policy-3 | Policy |
| Oncology (Oral - Proteasome Inhibitor) - Ninlaro PA Policy | Policy |
| Oncology (Oral - Proteasome Inhibitor) - Ninlaro PA Policy-1 | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Gavreto DQM - Per Rx | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Gavreto PA Policy | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Gavreto PA Policy-1 | Policy |