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.

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 - Kalydeco PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Kalydeco PA Policy-1	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Orkambi PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Orkambi PA Policy-1	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Symdeko PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Symdeko PA Policy-1	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Trikafta PA Policy	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Trikafta PA Policy-1	Policy
Dermatology - Hyftor PA	Policy
Dermatology - Opzelura PA Policy	Policy
Dermatology - Opzelura PA Policy-1	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 - Continuous Glucose Monitoring Systems PA Policy	Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy-1	Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy-2	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy-1	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy-1	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 - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy	Policy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy-1	Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy	Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy-1	Policy
Diabetes - Symlin PA Policy	Policy
Diabetes - Tzield PA Policy	Policy
Diuretics - Loop Products Step Therapy Policy	Policy
Droxidopa PA Policy	Policy
Enzyme Replacement Therapy - Aldurazyme PA Policy	Policy
Enzyme Replacement Therapy - Elaprase 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 - 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 Preferred Step Therapy Policy	Policy
Epinephrine Auto-Injectors Step Therapy Policy	Policy
Erectile Dysfunction - Alprostadil Products PA Policy	Policy
Erectile Dysfunction - Avanafil PA Policy	Policy
Erectile Dysfunction - Sildenafil PA Policy	Policy
Erectile Dysfunction - Tadalafil PA Policy	Policy
Erectile Dysfunction - Vardenafil PA Policy	Policy
Erectile Dysfunction Agents DQM Policy - Per Days	Policy
Erectile Dysfunction Agents DQM Policy - Per Days-1	Policy
Erectile Dysfunction Agents DQM Policy - Per Rx	Policy
Erectile Dysfunction Agents DQM Policy - Per Rx-1	Policy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy	Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy	Policy
Erythropoiesis-Stimulating Agents - Mircera PA Policy	Policy
Erythropoiesis-Stimulating Agents - Mircera PA Policy-1	Policy
Erythropoiesis-Stimulating Agents PSM Policy for High Performance and National Preferred Formularies	Policy
Estrogens (Topical) - Estradiol Gel DQM Policy - Per Rx	Policy
Estrogens (Topical) - Patches DQM Policy - Per Days	Policy
Fabry Disease - Galafold PA Policy	Policy
Gabapentin Step Therapy Policy	Policy
Gamifant PA Policy	Policy
Gamifant PA Policy-1	Policy
Gastroenterology - Eohilia DQM Policy - Per Days	Policy
Gastroenterology - Eohilia PA Policy	Policy
Gastroenterology - Gattex PA Policy	Policy
Gaucher Disease - Enzyme Replacement Therapy - Cerezyme PA Policy	Policy
Gaucher Disease - Enzyme Replacement Therapy - Elelyso PA Policy	Policy
Gaucher Disease - Enzyme Replacement Therapy - Vpriv PA Policy	Policy
Gaucher Disease - Substrate Reduction Therapy - Cerdelga PA Policy	Policy
Gaucher Disease - Substrate Reduction Therapy - Miglustat PA Policy	Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Implants PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Lupron Depot PA Policy	Policy
Gonadotropin-Releasing Hormone Antagonists - Myfembree PA Policy	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa DQM Policy - Per Rx and Per Days	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy	Policy
Gout - Krystexxa PA Policy	Policy
Gout Medications Step Therapy Policy	Policy
Graft Versus-Host Disease - Rezurock DQM Policy - Per Rx	Policy
Graft-Versus-Host Disease - Rezurock PA Policy	Policy
Growth Disorders - Growth Hormone PA Policy	Policy
Growth Disorders - Growth Hormone PA Policy-1	Policy
Growth Disorders - Growth Hormone PA Policy-2	Policy
Growth Disorders - Growth Hormone Short-Acting Products PSM Policy	Policy
Growth Disorders - Increlex PA Policy	Policy
Growth Disorders - Skytrofa PA Policy	Policy
Growth Disorders - Skytrofa PA Policy-1	Policy
Growth Disorders - Skytrofa PA Policy-2	Policy
Growth Disorders - Skytrofa PA Policy-3	Policy
Growth Disorders - Voxzogo PA Policy	Policy
Hematology - Cablivi PA Policy	Policy
Hematology - Ceprotin PA Policy	Policy

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