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.
| Inflammatory Conditions - Otezla PA Policy | Policy |
| Inflammatory Conditions - Otezla PA Policy-1 | Policy |
| Inflammatory Conditions - Rinvoq DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Rinvoq DQM Policy - Per Days-1 | Policy |
| Inflammatory Conditions - Rinvoq, Rinvoq LQ PA Policy | Policy |
| Inflammatory Conditions - Rinvoq, Rinvoq LQ PA Policy-1 | Policy |
| Inflammatory Conditions - Rinvoq, Rinvoq LQ PA Policy-2 | Policy |
| Inflammatory Conditions - Rinvoq, Rinvoq LQ PA Policy-3 | Policy |
| Inflammatory Conditions - Rinvoq, Rinvoq LQ PA Policy-4 | Policy |
| Inflammatory Conditions - Siliq DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Siliq PA Policy | Policy |
| Inflammatory Conditions - Siliq PA Policy-1 | Policy |
| Inflammatory Conditions - Siliq PA Policy-2 | Policy |
| Inflammatory Conditions - Simponi Aria PA Policy | Policy |
| Inflammatory Conditions - Simponi Subcutaneous DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Simponi Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Simponi Subcutaneous PA Policy-1 | Policy |
| Inflammatory Conditions - Simponi Subcutaneous PA Policy-2 | Policy |
| Inflammatory Conditions - Skyrizi Intravenous PA Policy | Policy |
| Inflammatory Conditions - Skyrizi Intravenous PA Policy-1 | Policy |
| Inflammatory Conditions - Skyrizi Subcutaneous DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Skyrizi Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Skyrizi Subcutaneous PA Policy-1 | Policy |
| Inflammatory Conditions - Skyrizi Subcutaneous PA Policy-2 | Policy |
| Inflammatory Conditions - Skyrizi Subcutaneous PA Policy-3 | Policy |
| Inflammatory Conditions - Spevigo Intravenous PA Policy | Policy |
| Inflammatory Conditions - Taltz DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Taltz PA Policy | Policy |
| Inflammatory Conditions - Taltz PA Policy-1 | Policy |
| Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy | Policy |
| Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy-1 | Policy |
| Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy-2 | Policy |
| Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy-3 | Policy |
| Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy-4 | Policy |
| Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy-5 | Policy |
| Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy-6 | Policy |
| Inflammatory Conditions - Tocilizumab Subcutaneous Products PA Policy | Policy |
| Inflammatory Conditions - Tocilizumab Subcutaneous Products PA Policy-1 | Policy |
| Inflammatory Conditions - Tocilizumab Subcutaneous Products PA Policy-2 | Policy |
| Inflammatory Conditions - Tocilizumab Subcutaneous Products PA Policy-3 | Policy |
| Inflammatory Conditions - Tremfya Subcutaneous DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Tremfya Subcutaneous DQM Policy - Per Days-1 | Policy |
| Inflammatory Conditions - Tremfya Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Tremfya Subcutaneous PA Policy-1 | Policy |
| Inflammatory Conditions - Tremfya Subcutaneous PA Policy-2 | Policy |
| Inflammatory Conditions - Tremfya Subcutaneous PA Policy-3 | Policy |
| Inflammatory Conditions - Tremfya Subcutaneous PA Policy-4 | Policy |
| Inflammatory Conditions - Ustekinumab Intravenous Products PA Policy | Policy |
| Inflammatory Conditions - Ustekinumab Intravenous Products PA Policy-1 | Policy |
| Inflammatory Conditions - Ustekinumab Intravenous Products PA Policy-2 | Policy |
| Inflammatory Conditions - Ustekinumab Intravenous Products PA Policy-3 | Policy |
| Inflammatory Conditions - Ustekinumab Intravenous Products PA Policy-4 | Policy |
| Inflammatory Conditions - Ustekinumab Intravenous Products PA Policy-5 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days-1 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days-2 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days-3 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days-4 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days-5 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days-6 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous Products PA Policy with Dosing | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous Products PA Policy with Dosing-1 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous Products PA Policy with Dosing-2 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous Products PA Policy with Dosing-3 | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous Products PA Policy with Dosing-4 | Policy |
| Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy | Policy |
| Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy-1 | Policy |
| Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy-2 | Policy |
| Inflammatory Conditions PSM Policy for FLEX Formulary | Policy |
| Inflammatory Conditions PSM Policy for FLEX Formulary-1 | Policy |
| Inflammatory Conditions PSM Policy for FLEX Formulary-2 | Policy |
| Inflammatory Conditions PSM Policy for FLEX Formulary-3 | Policy |
| Inflammatory Conditions PSM Policy for FLEX Formulary-4 | Policy |
| Inflammatory Conditions PSM Policy for FLEX Formulary-5 | Policy |
| Interferon - Actimmune PA Policy | Policy |
| Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy | Policy |
| Iron Replacement - Feraheme PA Policy | Policy |
| Iron Replacement - Feraheme PA Policy-1 | Policy |
| Iron Replacement - Ferrlecit PA Policy | Policy |
| Iron Replacement - Ferrlecit PA Policy-1 | Policy |
| Iron Replacement - INFeD PA Policy | Policy |
| Iron Replacement - Injectafer PA Policy | Policy |
| Iron Replacement - Monoferric PA Policy | Policy |
| Iron Replacement - Venofer PA Policy | Policy |
| Isotretinoin Step Therapy Policy | Policy |
| Lipodystrophy - Egrifta PA Policy | Policy |
| Lipodystrophy - Myalept PA Policy | Policy |
| Lofexidine PA Policy | Policy |
| Lupus - Benlysta Intravenous PA Policy | Policy |
| Lupus - Benlysta Intravenous PA Policy-1 | Policy |
| Lupus - Benlysta Subcutaneous DQM Policy - Per Days | Policy |
| Lupus - Benlysta Subcutaneous PA Policy | Policy |
| Lupus - Benlysta Subcutaneous PA Policy-1 | Policy |
| Lupus - Lupkynis PA Policy | Policy |
| Lupus - Lupkynis PA Policy-1 | Policy |
| Lupus - Saphnelo PA Policy | Policy |
| Metabolic Disorders - Betaine Anhydrous PA Policy | Policy |
| Metabolic Disorders - Betaine Anhydrous PSM Policy | Policy |
| Metabolic Disorders - Carbaglu PA Policy | Policy |
| Metabolic Disorders - Cysteamine Ophthalmic Solution PA Policy | Policy |