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.

Gout Medications Step Therapy Policy Policy
Graft Versus-Host Disease - Rezurock DQM Policy - Per Rx Policy
Graft-Versus-Host Disease - Rezurock PA Policy Policy
Graft-Versus-Host Disease - Ryoncil PA Policy Policy
Growth Disorders - Growth Hormone PA 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 - 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 - Gene Therapy - Roctavian PA Policy Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Alhemo 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
Hepatology - Bylvay DQM Policy - Per Rx Policy
Hepatology - Givlaari PA Policy Policy
Hepatology - Livmarli PA Policy Policy
Hepatology - Rezdiffra PA Policy Policy
Hepatology – Bylvay PA Policy Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PSM Policy Policy
Hereditary Angioedema - Ekterly DQM Policy - Per Days 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 - Prophylaxis Medications PSM Policy Policy
Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy Policy
Homozygous Familial Hypercholesterolemia - Juxtapid PA Policy Policy
Human Immunodeficiency Virus - Cabenuva DQM Policy - Per Days Policy
Human Immunodeficiency Virus - Cabenuva PA Policy Policy
Human Immunodeficiency Virus - Sunlenca PA Policy Policy
Human Immunodeficiency Virus - Trogarzo PA Policy Policy
Hyaluronic Acid Derivatives (Intraarticular) PA Policy Policy
Hydrocortisone Acetate Suppository Step Therapy Policy Policy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors DQM Policy - Per Rx Policy
Hyperhidrosis - Qbrexza PA Policy Policy
Hyperhidrosis - Sofdra PA Policy Policy
Hyperlipidemia - Nexletol PA Policy Policy
Hyperlipidemia - Nexlizet PA Policy Policy
Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy Policy
Hyperlipidemia - PCSK9 Inhibitors - Leqvio PA Policy Policy
Hyperlipidemia - PCSK9 Inhibitors - Praluent PA Policy Policy
Hyperlipidemia - PCSK9 Inhibitors - Repatha PA Policy Policy
Hyperlipidemia - PSCK9 Inhibitors - Lerochol PA Policy Policy
Hypertension - Clonidine Patches DQM Policy - Per Days Policy
Hypoactive Sexual Desire Disorder - Addyi PA Policy Policy
Hypoactive Sexual Desire Disorder - Vyleesi PA Policy Policy
Immune Globulin - Atgam PA Policy Policy
Immune Globulin – Cytogam PA Policy Policy
Immunologicals - Adbry DQM Policy - Per Days Policy
Immunologicals - Asthma PSM Policy Policy
Immunologicals - Dupixent DQM Policy - Per Days Policy
Immunologicals - Dupixent PA Policy Policy
Immunologicals - Exdensur PA Policy Policy
Immunologicals - Fasenra DQM Policy - Per Days Policy
Immunologicals - Fasenra PA Policy Policy
Immunologicals - Nemluvio PA Policy Policy
Immunologicals - Nucala DQM Policy - Per Days Policy
Immunologicals - Tezspire PA Policy Policy
Immunologicals - Xolair DQM Policy - Per Days Policy
Infectious Disease - Antiparasitics DQM Policy - Per Rx and Per Days Policy
Infectious Disease - Impavido PA Policy Policy
Infectious Disease - Ivermectin Tablets PA Policy Policy
Infectious Disease - Livtencity DQM Policy - Per Days Policy
Infectious Disease - Livtencity PA Policy Policy
Infectious Disease - Pretomanid PA Policy Policy
Infectious Disease - Prevymis DQM Policy - Per Rx and Per Days Policy
Infectious Disease - Pyrimethamine PA Policy Policy
Infectious Disease - Sirturo PA Policy Policy
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