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.

Lofexidine PA Policy Policy
Lupus - Benlysta Intravenous PA Policy Policy
Lupus - Benlysta Subcutaneous DQM Policy - Per Days Policy
Lupus - Benlysta Subcutaneous PA Policy Policy
Lupus - Lupkynis PA Policy Policy
Lupus - Saphnelo Intravenous PA Policy Policy
Lupus - Saphnelo Subcutaneous PA Policy Policy
Menkes Disease - Zycubo PA Policy Policy
Metabolic Disorders - Betaine Anhydrous PA Policy Policy
Metabolic Disorders - Betaine Anhydrous PSM Policy Policy
Metabolic Disorders - Carglumic Acid PA Policy Policy
Metabolic Disorders - Dojolvi PA Policy Policy
Metabolic Disorders - Imcivree PA Policy Policy
Metabolic Disorders - Nitisinone Products PA Policy Policy
Metabolic Disorders - Nulibry PA Policy Policy
Metabolic Disorders - Phenylbutyrate Products PSM Policy Policy
Metabolic Disorders - Primary Hyperoxaluria - Oxlumo PA Policy Policy
Metabolic Disorders - Primary Hyperoxaluria - Rivfloza PA Policy Policy
Metabolic Disorders - Tiopronin Products PA Policy Policy
Metabolic Disorders - Tiopronin Products PSM Policy Policy
Metabolic Disorders - Xuriden PA Policy Policy
Metabolic Disorders – Cysteamine Ophthalmic Solution PA Policy Policy
Methotrexate Injection Step Therapy Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Aimovig DQM Policy - Per Days Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality DQM Policy - Per Days Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Vyepti PA Policy Policy
Migraine - Elyxyb PA Policy Policy
Migraine - Nurtec ODT PA Policy Policy
Migraine - Qulipta PA Policy Policy
Migraine - Reyvow PA Policy Policy
Migraine - Ubrelvy PA Policy Policy
Migraine - Zavzpret PA Policy Policy
Migraine – Nonsteroidal Anti-Inflammatory Drugs DQM Policy – Per Days Policy
Migraine – Other Medications DQM Policy – Per Days Policy
Migraine – Triptans DQM Policy – Per Days Policy
Migraine Medication Step Therapy Policy Policy
Multiple Sclerosis - CD20-Directed Cytolytic Antibody Infused Products PSM Policy Policy
Multiple Sclerosis - Dalfampridine PSM Policy Policy
Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Kesimpta DQM Policy - Per Days Policy
Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Ocrevus and Ocrevus Zunovo DQM Policy - Per Days Policy
Multiple Sclerosis (Injectable - Other) - Lemtrada DQM Policy - Per Days Policy
Multiple Sclerosis (Injectable - Other) - Lemtrada PA Policy Policy
Multiple Sclerosis (Oral - Fumarate) - Bafiertam PA Policy Policy
Multiple Sclerosis (Oral - Fumarate) - Dimethyl Fumarate PA Policy Policy
Multiple Sclerosis (Oral - Other) - Teriflunomide PA Policy Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Mayzent PA Policy Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Ponvory DQM Policy - Per Days Policy
Multiple Sclerosis and Crohn's Disease (Injectable - Other) - Natalizumab Products PA Policy Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM Policy for High Performance Formulary 01.01.26 Policy
Multiple Sclerosis PSM Policy Policy
Muscular Dystrophy - Agamree PA Policy Policy
Muscular Dystrophy - Amondys 45 PA Policy Policy
Muscular Dystrophy - Deflazacort PA Policy Policy
Muscular Dystrophy - Deflazacort PSM Policy Policy
Muscular Dystrophy - Duvyzat PA Policy Policy
Muscular Dystrophy - Exondys 51 PA Policy Policy
Muscular Dystrophy - Gene Therapy - Elevidys PA Policy Policy
Muscular Dystrophy - Viltepso PA Policy Policy
Muscular Dystrophy - Vyondys 53 PA Policy Policy
Nephrology - Filspari PA Policy Policy
Nephrology - Jesduvroq PA Policy Policy
Nephrology - Tarpeyo PA Policy Policy
Nephrology - Trutakna PA Policy Policy
Nephrology - Vafseo PA Policy Policy
Nephrology - Vanrafia PA Policy Policy
Nephrology - Voyxact PA Policy Policy
Nephrology - Xphozah PA Policy Policy
Neurology - Brineura PA Policy Policy
Neurology - Daybue PA Policy Policy
Neurology - Edaravone Products PA Policy Policy
Neurology - Gene Therapy - Kebilidi PA Policy Policy
Neurology - Gene Therapy - Lenmeldy PA Policy Policy
Neurology - Gene Therapy - Skysona PA Policy Policy
Neurology - Imaavy PA Policy Policy
Neurology - Lyrica CR PA with Step Therapy Policy Policy
Neurology - Qalsody PA Policy Policy
Neurology - Riluzole Products PA Policy Policy
Neurology - Rystiggo PA Policy Policy
Neurology - Skyclarys PA Policy Policy
Neurology - Tonmya PA with Step Therapy Policy Policy
Neurology - Vyvgart Hytrulo PA Policy Policy
Neurology - Vyvgart Intravenous PA Policy Policy
Niemann-Pick disease type C - Aqneursa PA Policy Policy
Niemann-Pick Disease Type C - Miplyffa PA Policy Policy
Non-Steroidal Mineralocorticoid Receptor Antagonist - Kerendia PA Policy Policy
Nonsteroidal Anti-Inflammatory Drug - Tivorbex DQM Policy - Per Rx Policy
Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy Policy
Nuedexta PA Policy Policy
Oncology - (Oral - Epidermal Growth Factor Receptor Inhibitor) - Erlotinib DQM Policy - Per Rx Policy
Oncology - Abiraterone Acetate PSM Policy Policy
Oncology - Balversa PA Policy Policy
Oncology - Bexarotene (Oral) PA Policy Policy
Oncology - Bexarotene (Oral) PSM Policy Policy
Oncology - Bexarotene (Topical) PSM Policy Policy
Oncology - Bosulif DQM Policy - Per Rx Policy
Oncology - Cabometyx DQM Policy - Per Rx Policy
Oncology - Capecitabine DQM Policy - Per Rx Policy
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