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.

Hereditary Angioedema - Takhzyro PA 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 - Rukobia 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 with Step Therapy 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 - Lerochol PA Policy	Policy
Hyperlipidemia - PCSK9 Inhibitors - Lipfendra PA Policy	Policy
Hyperlipidemia - PCSK9 Inhibitors - Praluent PA Policy	Policy
Hyperlipidemia - PCSK9 Inhibitors - Repatha 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 - Yorvipath PA Policy	Policy
Immune Disorder - Joenja PA Policy	Policy
Immune Globulin - Atgam PA Policy	Policy
Immune Globulin - Intravenous PA Policy	Policy
Immune Globulin - Subcutaneous 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 - Ebglyss DQM Policy - Per Days	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
Immunologicals - Xolair PA Policy	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
Infectious Disease - Vancomycin (Oral) DQM Policy - Per Rx	Policy
Infectious Disease - Xifaxan DQM Policy - Per Rx	Policy
Infertility - Follitropins, Clomiphene PSM policy	Policy
Infertility - Gonadotropin-Releasing Hormone Antagonists PSM Policy	Policy
Inflammatory Conditions - Adalimumab Products Care Value Policy for High Performance Formulary	Policy
Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days	Policy
Inflammatory Conditions - Adalimumab Products PSM Policy for High Performance Formulary	Policy
Inflammatory Conditions - Arcalyst DQM Policy - Per Days	Policy
Inflammatory Conditions - Bimzelx DQM Policy - Per Days	Policy
Inflammatory Conditions - Cibinqo PA Policy	Policy
Inflammatory Conditions - Cosentyx Subcutaneous DQM Policy - Per Days	Policy
Inflammatory Conditions - Etanercept Products DQM Policy - Per Days	Policy
Inflammatory Conditions - Ilaris DQM Policy - Per Days	Policy
Inflammatory Conditions - Ilaris PA Policy	Policy
Inflammatory Conditions - Ilumya DQM Policy - Per Days	Policy
Inflammatory Conditions - Kineret DQM Policy - Per Days	Policy
Inflammatory Conditions - Leqselvi PA Policy	Policy
Inflammatory Conditions - Litfulo PA Policy	Policy
Inflammatory Conditions - Rinvoq DQM Policy - Per Days	Policy
Inflammatory Conditions - Siliq DQM Policy - Per Days	Policy
Inflammatory Conditions - Simponi Subcutaneous DQM Policy - Per Days	Policy
Inflammatory Conditions - Spevigo Intravenous PA Policy	Policy
Inflammatory Conditions - Spevigo Subcutaneous PA Policy	Policy
Inflammatory Conditions - Taltz DQM Policy - Per Days	Policy
Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy	Policy
Inflammatory Conditions - Tocilizumab Subcutaneous Products PA Policy	Policy
Inflammatory Conditions - Tofacitinib Products Care Value Policy for High Performance Formulary	Policy
Inflammatory Conditions - Tofacitinib Products PSM Policy for High Performance Formulary	Policy
Inflammatory Conditions - Tremfya Subcutaneous DQM Policy - Per Days	Policy
Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days	Policy
Inflammatory Conditions - Ustekinumab Subcutaneous Products Care Value Policy for High Performance Formulary	Policy
Inflammatory Conditions - Ustekinumab Subcutaneous Products PSM Policy for High Performance Formulary	Policy
Inflammatory Conditions - Zymfentra DQM Policy - Per Days	Policy
Inpefa PA Policy	Policy
Interferon - Actimmune PA Policy	Policy
Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy	Policy
Iron Replacement – Ferumoxytol PA Policy	Policy
Iron Replacement – INFeD PA Policy	Policy
Iron Replacement – Injectafer PA Policy	Policy
Iron Replacement – Iron Sucrose PA Policy	Policy
Iron Replacement – Monoferric PA Policy	Policy
Iron Replacement – Sodium Ferric Gluconate PA Policy	Policy
Isotretinoin Step Therapy Policy	Policy
Kygevvi PA Policy	Policy
Levothyroxine Products Step Therapy Policy	Policy
Lidocaine Patch Products PA Policy	Policy
Lipodystrophy - Egrifta PA Policy	Policy
Lipodystrophy - Myalept PA Policy	Policy

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