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.
| Oncology - Cometriq DQM Policy - Per Rx | Policy |
| Oncology - Copiktra DQM Policy - Per Rx | Policy |
| Oncology - Dasatinib Products DQM Policy - Per Rx | Policy |
| Oncology - Dasatinib Products PSM Policy | Policy |
| Oncology - Daurismo DQM Policy - Per Rx | Policy |
| Oncology - Daurismo PA Policy | Policy |
| Oncology - Exkivity PA Policy | Policy |
| Oncology - Fruzaqla PA Policy | Policy |
| Oncology - Gomekli PA Policy | Policy |
| Oncology - Iclusig PA Policy | Policy |
| Oncology - Idhifa PA Policy | Policy |
| Oncology - Imatinib DQM Policy - Per Rx | Policy |
| Oncology - Imatinib PSM Policy | Policy |
| Oncology - Inluriyo PA Policy | Policy |
| Oncology - Inrebic PA Policy | Policy |
| Oncology - Itovebi PA Policy | Policy |
| Oncology - Iwilfin PA Policy | Policy |
| Oncology - Koselugo PA Policy | Policy |
| Oncology - Lapatinib DQM Policy - Per Rx | Policy |
| Oncology - Lapatinib PA Policy | Policy |
| Oncology - Lonsurf PA Policy | Policy |
| Oncology - Mercaptopurine Products Step Therapy Policy | Policy |
| Oncology - Nilotinib PSM Policy | Policy |
| Oncology - Nilutamide PA Policy | Policy |
| Oncology - Ogsiveo PA Policy | Policy |
| Oncology - Ojjaara PA Policy | Policy |
| Oncology - Onureg PA Policy | Policy |
| Oncology - Orgovyx DQM Policy - Per Rx | Policy |
| Oncology - Orgovyx PA Policy | Policy |
| Oncology - Orserdu PA Policy | Policy |
| Oncology - Romvimza PA Policy | Policy |
| Oncology - Scemblix PA Policy | Policy |
| Oncology - Stivarga PA Policy | Policy |
| Oncology - Sunitinib DQM Policy - Per Rx | Policy |
| Oncology - Tazverik PA Policy | Policy |
| Oncology - Valchlor PA Policy | Policy |
| Oncology - Venclexta DQM policy - Per Rx | Policy |
| Oncology - Vistogard DQM Policy - Per Rx | Policy |
| Oncology - Vonjo PA Policy | Policy |
| Oncology - Xermelo DQM Policy - Per Rx | Policy |
| Oncology (Injectable - Alkylating agent) - Zepzelca PA Policy | Policy |
| Oncology (Injectable - Anti-GD2 Antibody) - Danyelza PA Policy | Policy |
| Oncology (Injectable - Anti-GD2 Antibody) - Unituxin PA Policy | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate – c-Met) - Emrelis PA Policy | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate – Trop-2) - Datroway PA Policy | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate – Trop-2) - Trodelvy PA Policy | Policy |
| Oncology (Injectable - Asparaginase) - Asparlas PA Policy | Policy |
| Oncology (Injectable - Asparaginase) - Oncaspar PA Policy | Policy |
| Oncology (Injectable - Asparaginase) - Rylaze PA Policy | Policy |
| Oncology (Injectable - Bispecific - BCMA-Directed) - Elrexfio PA Policy | Policy |
| Oncology (Injectable - Bispecific - BCMA-Directed) - Lynozyfic PA Policy | Policy |
| Oncology (Injectable - Bispecific - BCMA-Directed) - Tecvayli PA Policy | Policy |
| Oncology (Injectable - Bispecific - CD20-Directed) - Columvi PA Policy | Policy |
| Oncology (Injectable - Bispecific - CD20-Directed) - Epkinly PA Policy | Policy |
| Oncology (Injectable - Bispecific - CD20-Directed) - Lunsumio Intravenous PA Policy | Policy |
| Oncology (Injectable - Bispecific - CD20-Directed) - Lunsumio Velo PA Policy | Policy |
| Oncology (Injectable - Bispecific - GPRC5D-Directed) - Talvey PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Abecma PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Aucatzyl PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Breyanzi PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Carvykti PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Kymriah PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Tecartus PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Yescarta PA Policy | Policy |
| Oncology (Injectable - CD20-Directed Antibody) - Gazyva PA Policy | Policy |
| Oncology (Injectable - CD20-Directed Antibody) - Rituxan Hycela PA Policy | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Faspro PA Policy | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Intravenous PA Policy | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Sarclisa PA Policy | Policy |
| Oncology (Injectable - CTLA-4 Antibody) - Imjudo PA Policy | Policy |
| Oncology (Injectable - CTLA-4 Antibody) - Yervoy PA Policy | Policy |
| Oncology (Injectable - EGFR- and MET-Directed Antibody) - Rybrevant Faspro PA Policy | Policy |
| Oncology (Injectable - EGFR- and MET-Directed Antibody) - Rybrevant Intravenous PA Policy | Policy |
| Oncology (Injectable - Epidermal Growth Factor Receptor Inhibitor) - Erbitux PA Policy | Policy |
| Oncology (Injectable - Epidermal Growth Factor Receptor Inhibitor) - Vectibix PA Policy | Policy |
| Oncology (Injectable - HER2 Antagonist) - Perjeta PA Policy | Policy |
| Oncology (Injectable - HER2 Antagonist) - Phesgo PA Policy | Policy |
| Oncology (Injectable - Histone Deacetylase Inhibitor) - Beleodaq PA Policy | Policy |
| Oncology (Injectable - Histone Deacetylase Inhibitor) - Romidepsin Products PA Policy | Policy |
| Oncology (Injectable - Microtubule Inhibitor) - Halaven PA Policy | Policy |
| Oncology (Injectable - Microtubule Inhibitor) - Ixempra PA Policy | Policy |
| Oncology (Injectable - Microtubule Inhibitor) - Jevtana PA Policy | Policy |
| Oncology (Injectable - mTOR Inhibitor) - Fyarro PA Policy | Policy |
| Oncology (Injectable - mTOR Inhibitor) - Torisel PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Jemperli PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Keytruda Intravenous PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Keytruda Qlex PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Libtayo PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Loqtorzi PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdivo Intravenous PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdualag PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Tevimbra PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Zynyz PA Policy | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Bavencio PA Policy | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Imfinzi PA Policy | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq Hybreza PA Policy | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq Intravenous PA Policy | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Unloxcyt PA Policy | Policy |
| Oncology (Injectable - Proteasome Inhibitor) - Bortezomib Products PA Policy | Policy |
| Oncology (Injectable - Proteasome Inhibitor) - Kyprolis PA Policy | Policy |