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.
| Neurology - Gene Therapy - Skysona PA Policy-1 | Policy |
| Neurology - Leqembi Intravenous and Leqembi IQLIK PA Policy | Policy |
| Neurology - Leqembi PA Policy | Policy |
| Neurology - Oxybate Products PA Policy | Policy |
| Neurology - Oxybate Products PA Policy-1 | Policy |
| Neurology - Riluzole Products PA Policy | Policy |
| Neurology - Vyvgart Intravenous PA Policy | Policy |
| Neurology - Vyvgart Intravenous PA Policy-1 | Policy |
| Non-Steroidal Mineralocorticoid Receptor Antagonist - Kerendia PA Policy | Policy |
| Non-Steroidal Mineralocorticoid Receptor Antagonist - Kerendia PA Policy-1 | Policy |
| Non-Steroidal Mineralocorticoid Receptor Antagonist - Kerendia PA Policy-2 | Policy |
| Nonsteroidal Anti-Inflammatory Drug - Tivorbex DQM Policy - Per Rx | Policy |
| Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy | Policy |
| Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy-1 | Policy |
| Nuedexta PA Policy | Policy |
| Oncology - Abiraterone Acetate PA Policy | Policy |
| Oncology - Abiraterone Acetate PSM Policy | Policy |
| Oncology - Alecensa PA Policy | Policy |
| Oncology - Ayvakit PA Policy | Policy |
| Oncology - Balversa PA Policy | Policy |
| Oncology - Bexarotene (Oral) PA Policy | Policy |
| Oncology - Bexarotene (Oral) PSM Policy | Policy |
| Oncology - Bexarotene (Topical) PA Policy | Policy |
| Oncology - Bexarotene (Topical) PSM Policy | Policy |
| Oncology - Bosulif DQM Policy - Per Rx | Policy |
| Oncology - Bosulif PA Policy | Policy |
| Oncology - Braftovi PA Policy | Policy |
| Oncology - Brukinsa PA Policy | Policy |
| Oncology - Cabometyx DQM Policy - Per Rx | Policy |
| Oncology - Cabometyx PA Policy | Policy |
| Oncology - Cabometyx PA Policy-1 | Policy |
| Oncology - Calquence PA Policy | Policy |
| Oncology - Capecitabine PA Policy | Policy |
| Oncology - Capecitabine PSM Policy | Policy |
| Oncology - Caprelsa PA Policy | Policy |
| Oncology - Cometriq DQM Policy - Per Rx | Policy |
| Oncology - Cometriq PA Policy | Policy |
| Oncology - Copiktra PA Policy | Policy |
| Oncology - Cyclin Dependent Kinases 4,6 Inhibitors PSM Policy | Policy |
| Oncology - Dasatinib DQM Policy - Per Rx | Policy |
| Oncology - Dasatinib PA Policy | Policy |
| Oncology - Daurismo PA Policy | Policy |
| Oncology - Erivedge PA Policy | Policy |
| Oncology - Erleada PA Policy | Policy |
| Oncology - Erlotinib DQM Policy - Per Rx | Policy |
| Oncology - Erlotinib PA Policy | Policy |
| Oncology - Everolimus DQM Policy - Per Rx | Policy |
| Oncology - Everolimus Products PA Policy | Policy |
| Oncology - Everolimus Products PSM Policy | Policy |
| Oncology - Exkivity PA Policy | Policy |
| Oncology - Fotivda PA Policy | Policy |
| Oncology - Ibrance PA Policy | Policy |
| Oncology - Iclusig PA Policy | Policy |
| Oncology - Iclusig PA Policy-1 | Policy |
| Oncology - Idhifa PA Policy | Policy |
| Oncology - Imatinib DQM Policy - Per Rx | Policy |
| Oncology - Imatinib DQM Policy - Per Rx-1 | Policy |
| Oncology - Imatinib Products PA Policy | Policy |
| Oncology - Imatinib Products PA Policy-1 | Policy |
| Oncology - Imatinib PSM Policy | Policy |
| Oncology - Imbruvica PSM Policy | Policy |
| Oncology - Inlyta PA Policy | Policy |
| Oncology - Inqovi PA Policy | Policy |
| Oncology - Jakafi PA Policy | Policy |
| Oncology - Jakafi PA Policy-1 | Policy |
| Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy | Policy |
| Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy-1 | Policy |
| Oncology - Koselugo PA Policy | Policy |
| Oncology - Koselugo PA Policy-1 | Policy |
| Oncology - Koselugo PA Policy-2 | Policy |
| Oncology - Koselugo PA Policy-3 | Policy |
| Oncology - Krazati PA Policy | Policy |
| Oncology - Lapatinib DQM Policy - Per Rx | Policy |
| Oncology - Lenvima PA Policy | Policy |
| Oncology - Lonsurf PA Policy | Policy |
| Oncology - Lumakras PA Policy | Policy |
| Oncology - Lynparza PA Policy | Policy |
| Oncology - Nerlynx PA Policy | Policy |
| Oncology - Nilotinib Products PA Policy | Policy |
| Oncology - Nilotinib Products PA Policy-1 | Policy |
| Oncology - Nilutamide PA Policy | Policy |
| Oncology - Nubeqa PA Policy | Policy |
| Oncology - Odomzo PA Policy | Policy |
| Oncology - Onureg PA Policy | Policy |
| Oncology - Orgovyx DQM Policy - Per Rx | Policy |
| Oncology - Orgovyx PA Policy | Policy |
| Oncology - Pazopanib PA Policy | Policy |
| Oncology - Piqray PA Policy | Policy |
| Oncology - Qinlock DQM Policy - Per Rx | Policy |
| Oncology - Qinlock DQM Policy - Per Rx-1 | Policy |
| Oncology - Qinlock PA Policy | Policy |
| Oncology - Rezlidhia PA Policy | Policy |
| Oncology - Rozlytrek DQM Policy - Per Rx | Policy |
| Oncology - Rubraca PA Policy | Policy |
| Oncology - Rydapt PA Policy | Policy |
| Oncology - Scemblix PA Policy | Policy |
| Oncology - Scemblix PA Policy-1 | Policy |
| Oncology - Sorafenib PA Policy | Policy |
| Oncology - Sorafenib PSM Policy | Policy |
| Oncology - Stivarga PA Policy | Policy |