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 (Injectable - Topoisomerase Inhibitor) - Onivyde PA Policy | Policy |
| Oncology (Injectable - Topoisomerase Inhibitor) - Topotecan Products PA Policy | Policy |
| Oncology (Injectable - Vascular Endothelial Growth Factor Inhibitors) - Zaltrap PA Policy | Policy |
| Oncology (Injectable – Antibody-Drug Conjugate – CD123) – Decnupaz PA Policy | Policy |
| Oncology (Injectable – Antibody-Drug Conjugate – CD19) - Monjuvi PA Policy | Policy |
| Oncology (Injectable – Antibody-Drug Conjugate – CD22) – Besponsa PA Policy | Policy |
| Oncology (Injectable – Programmed Death Receptor-1) – Opdivo Qvantig PA Policy | Policy |
| Oncology (Injectable – T-Cell Immunotherapy – MAGE-A4) - Tecelra PA Policy | Policy |
| Oncology (Injectable) - Adcetris PA Policy | Policy |
| Oncology (Injectable) - Amtagvi PA Policy | Policy |
| Oncology (Injectable) - Arsenic Trioxide PA Policy | Policy |
| Oncology (Injectable) - Azedra PA Policy | Policy |
| Oncology (Injectable) - Bendamustine Products PA Policy | Policy |
| Oncology (Injectable) - Besremi Products PA Policy | Policy |
| Oncology (Injectable) - Bevacizumab Products PSM Policy | Policy |
| Oncology (Injectable) - Bizengri PA Policy | Policy |
| Oncology (Injectable) - Blenrep PA Policy | Policy |
| Oncology (Injectable) - Blincyto PA Policy | Policy |
| Oncology (Injectable) - Carmustine Products PA Policy | Policy |
| Oncology (Injectable) - Cosela PA Policy | Policy |
| Oncology (Injectable) - Cyramza PA Policy | Policy |
| Oncology (Injectable) - Decitabine Products PA Policy | Policy |
| Oncology (Injectable) - Elahere PA Policy | Policy |
| Oncology (Injectable) - Elzonris PA Policy | Policy |
| Oncology (Injectable) - Empliciti PA Policy | Policy |
| Oncology (Injectable) - Fulvestrant PA Policy | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy | Policy |
| Oncology (Injectable) - Imdelltra PA Policy | Policy |
| Oncology (Injectable) - Imlygic PA Policy | Policy |
| Oncology (Injectable) - Kimmtrak PA Policy | Policy |
| Oncology (Injectable) - Levoleucovorin Products PA Policy | Policy |
| Oncology (Injectable) - Lymphir PA Policy | Policy |
| Oncology (Injectable) - Margenza PA Policy | Policy |
| Oncology (Injectable) - Mylotarg PA Policy | Policy |
| Oncology (Injectable) - Padcev PA Policy | Policy |
| Oncology (Injectable) - Polivy PA Policy | Policy |
| Oncology (Injectable) - Portrazza PA Policy | Policy |
| Oncology (Injectable) - Poteligeo PA Policy | Policy |
| Oncology (Injectable) - Pralatrexate Products PA Policy | Policy |
| Oncology (Injectable) - Proleukin PA Policy | Policy |
| Oncology (Injectable) - Sylvant PA Policy | Policy |
| Oncology (Injectable) - Thiotepa Products PA Policy | Policy |
| Oncology (Injectable) - Tivdak PA Policy | Policy |
| Oncology (Injectable) - Vyloy PA Policy | Policy |
| Oncology (Injectable) - Vyxeos PA Policy | Policy |
| Oncology (Injectable) - Ziihera PA Policy | Policy |
| Oncology (Injectable) - Zynlonta PA Policy | Policy |
| Oncology (Intravesical) - Adstiladrin PA Policy | Policy |
| Oncology (Intravesical) - Anktiva PA Policy | Policy |
| Oncology (Intravesical) - Inlexzo PA Policy | Policy |
| Oncology (Intravesical) - Valrubicin Products PA Policy | Policy |
| Oncology (Intravesical) - Zusduri PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alecensa PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alunbrig PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Ensacove PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Lorbrena PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Xalkori - Per Rx | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Xalkori PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Zykadia PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase-Positive Agent) - Alunbrig DQM Policy - Per Rx | Policy |
| Oncology (Oral - Androgen Biosynthesis Inhibitor) - Yonsa PA Policy | Policy |
| Oncology (Oral - Androgen Biosynthesis Inhibitor) – Abiraterone Acetate DQM Policy - Per Rx | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Erleada PA Policy | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Nubeqa PA Policy | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Xtandi DQM Policy - Per Rx | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Xtandi PA Policy | Policy |
| Oncology (Oral - BCL-2 Inhibitor) - Venclexta PA Policy | Policy |
| Oncology (Oral - BRAF Inhibitor) - Braftovi PA Policy | Policy |
| Oncology (Oral - BRAF Inhibitor) - Tafinlar PA Policy | Policy |
| Oncology (Oral - BRAF Inhibitor) - Zelboraf DQM Policy - Per Rx | Policy |
| Oncology (Oral - BRAF Inhibitor) - Zelboraf PA Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Brukinsa PA Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Calquence PA Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Imbruvica PSM Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Jaypirca PA Policy | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) – Imbruvica DQM Policy - Per Rx | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Ibrance PA Policy | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Kisqali and Kisqali Femara Co-Pack PA Policy | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Verzenio PA Policy | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 46 Inhibitor) – Ibrance DQM Policy - Per Rx | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Erlotinib PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gefitinib DQM Policy - Per Rx | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gefitinib PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gilotrif PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Lazcluze PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Tagrisso PA Policy | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Vizimpro PA Policy | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Lytgobi PA Policy | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Pemazyre PA Policy | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Rydapt PA Policy | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Vanflyta PA Policy | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Xospata PA Policy | Policy |
| Oncology (Oral - Hedgehog Pathway Inhibitor) - Erivedge PA Policy | Policy |
| Oncology (Oral - Hedgehog Pathway Inhibitor) - Odomzo PA Policy | Policy |
| Oncology (Oral - HER2 Inhibitor) - Hernexeos PA Policy | Policy |
| Oncology (Oral - HER2 Inhibitor) - Hyrnuo PA Policy | Policy |
| Oncology (Oral - Histone Deacetylase Inhibitor) - Zolinza PA Policy | Policy |
| Oncology (Oral - Immunomodulator) - Lenalidomide PSM Policy | Policy |
| Oncology (Oral - Immunomodulator) - Pomalidomide PA Policy | Policy |