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 - Rearranged During Transfection-Targeting Agent) - Retevmo PA Policy	Policy
Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Retevmo PA Policy-1	Policy
Oncology (Other) - Jelmyto PA Policy	Policy
Ophthalmic - Glaucoma - Beta-Adrenergic Blockers Step Therapy Policy	Policy
Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Step Therapy Policy	Policy
Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy	Policy
Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy-1	Policy
Ophthalmic - Glaucoma - Prostaglandins PA Policy	Policy
Ophthalmic - Glaucoma - Prostaglandins PA Policy-1	Policy
Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy	Policy
Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy	Policy
Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy-1	Policy
Ophthalmic Corticosteroids Step Therapy Policy	Policy
Ophthalmic Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy	Policy
Ophthalmology - Dry Eye Disease - Cyclosporine Products PA	Policy
Ophthalmology - Dry Eye Disease - Cyclosporine Products PA Policy	Policy
Ophthalmology - Dry Eye Disease - Eysuvis PA Policy	Policy
Ophthalmology - Dry Eye Disease - Lacrisert DQM Policy - Per Rx	Policy
Ophthalmology - Dry Eye Disease - Lacrisert PA Policy	Policy
Ophthalmology - Dry Eye Disease - Xiidra PA Policy	Policy
Ophthalmology - Dry Eye Disease - Xiidra PA Policy-1	Policy
Ophthalmology - Durysta PA Policy	Policy
Ophthalmology - Gene Therapy - Luxturna PA Policy	Policy
Ophthalmology - Oxervate PA Policy	Policy
Ophthalmology - Oxervate PA Policy-1	Policy
Ophthalmology - Oxervate PA Policy-2	Policy
Ophthalmology - Oxervate PA Policy-3	Policy
Ophthalmology - Tepezza PA Policy	Policy
Ophthalmology - Upneeq PA Policy	Policy
Ophthalmology - Upneeq PA Policy-1	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Aflibercept Products PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Aflibercept Products PA Policy-1	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Ranibizumab Products PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA Policy-1	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA Policy-2	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA Policy-1	Policy
Ophthalmology - Verkazia PA Policy	Policy
Opioids - Butorphanol DQM Policy - Per Days	Policy
Opioids - Fentanyl Transdermal Products DQM Policy - Per Days	Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy	Policy
Opioids - Fentanyl Transmucosal Products DQM Policy - Per Days	Policy
Opioids - Long-Acting Products PA Policy	Policy
Opioids - Morphine Milligram Equivalent (200) DQM Policy	Policy
Opioids - Morphine Milligram Equivalent (90) DQM Policy	Policy
Opioids - Nucynta DQM Policy - Per Rx	Policy
Opioids - Nucynta DQM Policy - Per Rx-1	Policy
Opioids - Short-Acting Products DQM Policy (Adults) - Per Rx	Policy
Opioids - Short-Acting Products DQM Policy (All Ages) - Per Rx	Policy
Opioids - Short-Acting Products DQM Policy (Pediatrics) - Per Rx	Policy
Opioids - Tramadol Extended-Release Products DQM Policy - Per Rx	Policy
Overactive Bladder Medications Preferred Step Therapy Policy	Policy
Overactive Bladder Medications Step Therapy Policy	Policy
Overactive Bladder Medications Step Therapy Policy-1	Policy
Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy Policy	Policy
Parkinson’s Disease - Apomorphine Subcutaneous (Apokyn) PA Policy	Policy
Parkinson’s Disease - Apomorphine Subcutaneous PA Policy	Policy
Parkinson’s Disease - Carbidopa PA Policy	Policy
Parkinson’s Disease - Duopa PA Policy	Policy
Parkinson’s Disease - Inbrija PA Policy	Policy
Parkinson's Disease - Kynmobi PA Policy	Policy
Parkinson's Disease - Monoamine Oxidase Type B Inhibitors Step Therapy Policy	Policy
Parkinson’s Disease - Nourianz PA Policy	Policy
Parkinson’s Disease - Nuplazid PA Policy	Policy
Parkinson's Disease - Ongentys PA Policy	Policy
Parkinson’s Disease - Tolcapone PA Policy	Policy
Phenylketonuria - Palynziq DQM Policy - Per Rx	Policy
Phenylketonuria - Palynziq PA Policy	Policy
Phenylketonuria - Palynziq PA Policy-1	Policy
Phenylketonuria - Sapropterin PA Policy	Policy
Phenylketonuria - Sapropterin PA Policy-1	Policy
Phenylketonuria - Sapropterin PA Policy-2	Policy
Phosphate Binders DQM Policy - Per Rx	Policy
Pompe Disease - Enzyme Replacement Therapy - Lumizyme PA Policy	Policy
Pompe Disease - Enzyme Replacement Therapy - Nexviazyme PA Policy	Policy
Potassium Binders - Lokelma DQM Policy - Per Rx	Policy
Potassium Binders - Veltassa DQM Policy - Per Rx	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy-1	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy-2	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Repatha DQM Policy - Per Days	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Related Products - Leqvio PA Policy	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Related Products - Leqvio PA Policy-1	Policy
Proton Pump Inhibitors DQM Policy - Per Rx	Policy
Proton Pump Inhibitors Step Therapy Policy	Policy
Psychiatry - Novel Psychotropics DQM Policy - Per Rx	Policy
Psychiatry - Spravato PA Policy	Policy
Psychiatry - Spravato PA Policy-1	Policy
Psychiatry - Spravato PA Policy-2	Policy
Psychiatry - Zulresso PA Policy	Policy
Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy	Policy
Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy-1	Policy
Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy-2	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers DQM Policy - Per Rx	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy	Policy
Pulmonary - Roflumilast PA with Step Therapy Policy	Policy
Pulmonary - Roflumilast PA with Step Therapy Policy-1	Policy

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