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.

Hematology - Coagadex PA Policy	Policy
Hematology - Corifact PA Policy	Policy
Hematology - Enjaymo PA Policy	Policy
Hematology - Fibrinogen Products PA Policy	Policy
Hematology - Gene Therapy - Zynteglo PA Policy	Policy
Hematology - Gene Therapy - Zynteglo PA Policy-1	Policy
Hematology - Pyrukynd PA Policy	Policy
Hematology - Reblozyl PA Policy	Policy
Hematology - Ryplazim 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 - Factor VIII Products PA Policy	Policy
Hemophilia - FEIBA PA Policy	Policy
Hemophilia - Gene Therapy - Beqvez PA Policy	Policy
Hemophilia - Gene Therapy - Hemgenix PA Policy	Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Hemlibra PA Policy	Policy
Hemophilia - Recombinant Factor VIII Products PSM Policy	Policy
Hepatitis C - Epclusa DQM Policy - Per Days	Policy
Hepatitis C - Epclusa PA Policy	Policy
Hepatitis C - Harvoni DQM Policy - Per Days	Policy
Hepatitis C - Harvoni PA Policy	Policy
Hepatitis C - Mavyret DQM Policy - Per Days	Policy
Hepatitis C - Mavyret DQM Policy - Per Days-1	Policy
Hepatitis C - Mavyret DQM Policy - Per Days-2	Policy
Hepatitis C - Mavyret DQM Policy - Per Days-3	Policy
Hepatitis C - Mavyret PA for PSM Policy	Policy
Hepatitis C - Mavyret PA for PSM Policy-1	Policy
Hepatitis C - Mavyret PA for PSM Policy-2	Policy
Hepatitis C - Mavyret PA Policy	Policy
Hepatitis C - Mavyret PA Policy-1	Policy
Hepatitis C - Sovaldi DQM Policy - Per Days	Policy
Hepatitis C - Sovaldi PA Policy	Policy
Hepatitis C - Vosevi PA Policy	Policy
Hepatitis C - Zepatier PA Policy	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for High Performance Formulary	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for High Performance Formulary-1	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred FLEX Formulary	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred FLEX Formulary-1	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred Formulary and Basic Formulary	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred Formulary and Basic Formulary-1	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred Formulary and Basic Formulary-2	Policy
Hepatology - Bylvay DQM Policy - Per Rx	Policy
Hepatology - Bylvay PA Policy	Policy
Hepatology - Givlaari PA Policy	Policy
Hepatology - Livmarli PA Policy	Policy
Hepatology - Ocaliva 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 - C1 Esterase Inhibitors (Intravenous) PSM Policy-1	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy	Policy
Hereditary Angioedema - Icatibant PA Policy	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 - Orladeyo PA Policy-1	Policy
Hereditary Angioedema - Orladeyo PA Policy-2	Policy
Hereditary Angioedema - Takhzyro PA Policy	Policy
Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy	Policy
Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy-1	Policy
Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy-2	Policy
Homozygous Familial Hypercholesterolemia - Juxtapid PA Policy	Policy
Human Immunodeficiency Virus - Apretude PA Policy	Policy
Human Immunodeficiency Virus - Cabenuva DQM Policy - Per Days	Policy
Human Immunodeficiency Virus - Cabenuva PA Policy	Policy
Human Immunodeficiency Virus - Complera PSM Policy (Basic Formulary)	Policy
Human Immunodeficiency Virus - Prezcobix PSM Policy (Basic Formulary)	Policy
Human Immunodeficiency Virus - Rukobia PA Policy	Policy
Human Immunodeficiency Virus - Stribild PSM Policy (Basic Formulary)	Policy
Human Immunodeficiency Virus - Sunlenca PA Policy	Policy
Human Immunodeficiency Virus - Trogarzo PA Policy	Policy
Human Immunodeficiency Virus - Truvada PSM Policy	Policy
Hyaluronic Acid Derivatives (Intraarticular) PSM Policy	Policy
Hydrocortisone Acetate Suppository Step Therapy Policy	Policy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors DQM Policy - Per Rx	Policy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors Step Therapy Policy	Policy
Hyperhidrosis - Qbrexza PA Policy	Policy
Hyperlipidemia - Nexletol PA Policy	Policy
Hyperlipidemia - Nexlizet PA Policy	Policy
Hyperlipidemia - Omega-3 Fatty Acid Products 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
Hypoparathyroidism - Natpara PA Policy	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy-1	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy-2	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PA Policy	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PA Policy-1	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PSM Policy	Policy
Immune Globulin - Atgam PA Policy	Policy
Immune Globulin - Cytogam PA Policy	Policy
Immune Globulin - Intravenous PA Policy	Policy
Immune Globulin - Subcutaneous PA Policy	Policy
Immunologicals - Adbry DQM Policy - Per Days	Policy

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