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.

Topical Medications for Actinic Keratosis Preferred Step Therapy Policy	Policy
Topical Medications for Inflammatory Rosacea Step Therapy	Policy
Topical Podofilox Products Step Therapy Policy	Policy
Topical Products - Vtama and Zoryve 0.3% Cream Step Therapy Policy	Policy
Topical Products - Vtama and Zoryve 0.3% Cream Step Therapy Policy-1	Policy
Topical Products - Vtama and Zoryve 0.3% Cream Step Therapy Policy-2	Policy
Topical Products - Vtama and Zoryve 0.3% Cream Step Therapy Policy-3	Policy
Topical Retinoids - Aklief PA Policy	Policy
Topical Retinoids - Aklief PA Policy-1	Policy
Topical Retinoids - Panretin PA Policy	Policy
Topical Retinoids - Panretin PA Policy-1	Policy
Topical Retinoids - Tazarotene Products PA Policy	Policy
Topical Retinoids - Tazarotene Products PA Policy-1	Policy
Topical Vitamin D Analogs Step Therapy Policy	Policy
Transplantation - Grafapex PA Policy	Policy
Uplizna PA Policy	Policy
Uplizna PA Policy-1	Policy
Uplizna PA Policy-2	Policy
Uplizna PA Policy-3	Policy
Uplizna PA Policy-4	Policy
Vasculitis - Tavneos PA Policy	Policy
Vecamyl PA Policy	Policy
Veregen PA Policy	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza Products PA Policy	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors DQM Policy - Per Rx	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy	Policy
Vijoice PA Policy	Policy
Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy	Policy
Vitamin D Analog (Oral) Step Therapy Policy	Policy
Wakefulness-Promoting Agents - Sunosi DQM Policy - Per Rx	Policy
Wakefulness-Promoting Agents - Wakix DQM Policy - Per Rx	Policy
Weight Loss - Appetite Suppressants and Orlistat PA Policy	Policy
Weight Loss - Appetite Suppressants and Orlistat PA Policy-1	Policy
Weight Loss - Appetite Suppressants and Orlistat PA Policy-2	Policy
Weight Loss - Appetite Suppressants and Orlistat PA Policy-3	Policy
Weight Loss - Appetite Suppressants and Orlistat PA Policy-4	Policy
Weight Loss - Phentermine and Topiramate DQM Policy - Per Rx	Policy
Weight Loss - Wegovy DQM Policy - Per Days	Policy
Weight Loss - Wegovy DQM Policy - Per Days-1	Policy
Xiaflex PA Policy	Policy
Zokinvy PA Policy	Policy

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