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.

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
Familial Chylomicronemia Syndrome PSM Policy	Policy
Fenofibrate Step Therapy Policy	Policy
Firdapse PA Policy	Policy
Gabapentin Step Therapy Policy	Policy
Gamifant PA Policy	Policy
Gastroenterology - Eohilia DQM Policy - Per Days	Policy
Gastroenterology - Eohilia PA Policy	Policy
Gastroenterology - Gattex PA Policy	Policy
Gastroenterology - Gimoti PA Policy	Policy
Gaucher Disease - Enzyme Replacement Therapy - Cerezyme PA Policy	Policy
Gaucher Disease - Enzyme Replacement Therapy PSM Policy	Policy
Gaucher Disease - Substrate Reduction Therapy - Cerdelga PA Policy	Policy
Gaucher Disease - Substrate Reduction Therapy - Miglustat PA Policy	Policy
Gaucher Disease - Substrate Reduction Therapy PSM Policy	Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty 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 - Oriahnn PA Policy	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa DQM Policy - Per Rx and Per Days	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 - Niktimvo PA Policy	Policy
Graft-Versus-Host Disease - Rezurock PA Policy	Policy
Graft-Versus-Host Disease - Ryoncil PA Policy	Policy
Graft-Versus-Host Disease - Tregzi PA Policy	Policy
Growth Disorders - Growth Hormone PA Policy	Policy
Growth Disorders - Growth Hormone Short-Acting Products PSM Policy	Policy
Growth Disorders - Increlex PA Policy	Policy
Growth Disorders - Ngenla PA Policy	Policy
Growth Disorders - Skytrofa PA Policy	Policy
Growth Disorders - Sogroya PA Policy	Policy
Growth Disorders - Voxzogo PA Policy	Policy
Growth Disorders - Yuviwel PA Policy	Policy
Hematology - Adzynma PA Policy	Policy
Hematology - Aphexda PA Policy	Policy
Hematology - Aqvesme PA Policy	Policy
Hematology - Cablivi PA Policy	Policy
Hematology - Ceprotin PA Policy	Policy
Hematology - Coagadex PA Policy	Policy
Hematology - Corifact PA Policy	Policy
Hematology - Enjaymo PA Policy	Policy
Hematology - Fibrinogen Products PA Policy	Policy
Hematology - Gene Therapy - Casgevy PA Policy	Policy
Hematology - Gene Therapy - Lyfgenia PA Policy	Policy
Hematology - Gene Therapy - Zynteglo PA Policy	Policy
Hematology - Pyrukynd DQM Policy - Per Days	Policy
Hematology - Pyrukynd PA Policy	Policy
Hematology - Reblozyl PA Policy	Policy
Hematology - Ryplazim PA Policy	Policy
Hematology - Rytelo PA Policy	Policy
Hematology - Tretten PA Policy	Policy
Hematology - Vonvendi PA Policy	Policy
Hemophilia - Altuviiio PA Policy	Policy
Hemophilia - Eptacog Products - NovoSeven RT PA Policy	Policy
Hemophilia - Eptacog Products - Sevenfact PA Policy	Policy
Hemophilia - Factor IX Products PA Policy	Policy
Hemophilia - FEIBA PA Policy	Policy
Hemophilia - Gene Therapy - Hemgenix PA Policy	Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Alhemo PA Policy	Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Hemlibra PA Policy	Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Hympavzi PA Policy	Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Qfitlia PA Policy	Policy
Hemophilia - Recombinant Factor IX Products PSM Policy	Policy
Hemophilia - Recombinant Factor VIII Products PSM Policy	Policy
Hepatitis C - Epclusa DQM Policy - Per Days	Policy
Hepatitis C - Harvoni DQM Policy - Per Days	Policy
Hepatitis C - Mavyret DQM Policy - Per Days	Policy
Hepatitis C - Mavyret PA for PSM Policy	Policy
Hepatitis C - Sovaldi DQM Policy - Per Days	Policy
Hepatitis C - Zepatier DQM Policy - Per Days	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for High Performance Formulary	Policy
Hepatitis D Virus - Hepcludex PA Policy	Policy
Hepatology - Bylvay DQM Policy - Per Rx	Policy
Hepatology - Givlaari PA Policy	Policy
Hepatology - Livmarli PA Policy	Policy
Hepatology - Lynavoy PA Policy	Policy
Hepatology - Rezdiffra PA Policy	Policy
Hepatology – Bylvay PA Policy	Policy
Hepatology – Peroxisome Proliferator-Activated Receptor Agonists PSM Policy	Policy
Hereditary Angioedema - Andembry PA Policy	Policy
Hereditary Angioedema - Berinert and Cinryze DQM Policy - Per Days	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PSM Policy	Policy
Hereditary Angioedema - Ekterly DQM Policy - Per Days	Policy
Hereditary Angioedema - Ekterly PA Policy	Policy
Hereditary Angioedema - Haegarda DQM Policy - Per Days	Policy
Hereditary Angioedema - Icatibant DQM Policy - Per Days	Policy
Hereditary Angioedema - Icatibant PSM Policy	Policy
Hereditary Angioedema - Kalbitor DQM Policy - Per Days	Policy
Hereditary Angioedema - Kalbitor PA Policy	Policy
Hereditary Angioedema - Orladeyo PA Policy	Policy
Hereditary Angioedema - Prophylaxis Medications PSM Policy	Policy
Hereditary Angioedema - Ruconest DQM Policy - Per Days	Policy

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