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) - 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) - Trastuzumab Products PSM 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 - BRAF Inhibitor) - Braftovi PA Policy | Policy |
| Oncology (Oral - BRAF Inhibitor) - Tafinlar PA Policy | 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) - Jaypirca PA Policy | 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) - 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 - Immunomodulator) - Lenalidomide PSM Policy | Policy |
| Oncology (Oral - Immunomodulator) - Pomalidomide PA Policy | Policy |
| Oncology (Oral - Immunomodulator) - Thalomid DQM Policy - Per Rx | Policy |
| Oncology (Oral - Immunomodulator) - Thalomid PA Policy | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Rezlidhia PA Policy | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Tibsovo PA Policy | Policy |
| Oncology (Oral - Kirsten RAt Sarcoma Virus Inhibitor) - Krazati PA Policy | Policy |
| Oncology (Oral - Kirsten RAt Sarcoma Virus Inhibitor) - Lumakras PA Policy | Policy |
| Oncology (Oral - MEK Inhibitor) - Cotellic PA Policy | Policy |
| Oncology (Oral - MEK Inhibitor) - Mekinist PA Policy | Policy |
| Oncology (Oral - MEK Inhibitor) - Mektovi PA Policy | Policy |
| Oncology (Oral - Menin Inhibitor) - Komzifti PA Policy | Policy |
| Oncology (Oral - Menin Inhibitor) - Revuforj PA Policy | Policy |
| Oncology (Oral - Mesenchymal-Epithelial Transition Skipping Agent) - Tabrecta PA Policy | Policy |
| Oncology (Oral - Mesenchymal-Epithelial Transition Skipping Agent) - Tepmetko PA Policy | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Augtyro PA Policy | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Rozlytrek DQM Policy - Per Rx | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Rozlytrek PA Policy | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Vitrakvi PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Akeega PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Lynparza PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Rubraca PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Talzenna PA Policy | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Zejula PA Policy | Policy |
| Oncology (Oral - Proteasome Inhibitor) - Ninlaro PA Policy | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Gavreto PA Policy | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Retevmo PA Policy | Policy |
| Oncology (Oral - ROS1 Inhibitor) - Ibtrozi PA Policy | Policy |
| Oncology (Oral – Bruton's Tyrosine Kinase Inhibitor) – Calquence DQM Policy – Per Rx | Policy |
| Oncology (Oral – Bruton's Tyrosine Kinase Inhibitor) – Jaypirca DQM Policy – Per Rx | Policy |
| Oncology (Oral – Epidermal Growth Factor Receptor Inhibitor) - Tagrisso DQM Policy - Per Rx | Policy |
| Oncology (Oral – Rearranged During Transfection-Targeting Agent) – Gavreto DQM - Per Rx | Policy |
| Oncology (Other) - Jelmyto PA Policy | Policy |