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 (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 - KRAS 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 - RET-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 – Immunomodulator) – Pomalidomide PSM Policy | Policy |
| Oncology (Oral – Neurotrophic Tyrosine Receptor Kinase Gene Fusion) – Vitrakvi DQM Policy – Per Rx | Policy |
| Oncology (Oral – Rearranged During Transfection-Targeting Agent) – Gavreto DQM - Per Rx | Policy |
| Oncology (Oral) - Avmapki Fakzynja PA Policy | Policy |
| Oncology (Oral) - Ayvakit PA Policy | Policy |
| Oncology (Oral) - Bosutinib PA Policy | Policy |
| Oncology (Oral) - Cabometyx PA Policy | Policy |
| Oncology (Oral) - Capecitabine PSM Policy | Policy |
| Oncology (Oral) - Caprelsa PA Policy | Policy |
| Oncology (Oral) - Cometriq PA Policy | Policy |
| Oncology (Oral) - Copiktra PA Policy | Policy |
| Oncology (Oral) - Everolimus Products DQM Policy - Per Rx | Policy |
| Oncology (Oral) - Everolimus Products PSM Policy | Policy |
| Oncology (Oral) - Fotivda PA Policy | Policy |
| Oncology (Oral) - Inlyta PA Policy | Policy |
| Oncology (Oral) - Inqovi PA Policy | Policy |
| Oncology (Oral) - Jakafi Jakafi XR PA Policy | Policy |
| Oncology (Oral) - Lenvima PA Policy | Policy |
| Oncology (Oral) - Lifyorli PA Policy | Policy |
| Oncology (Oral) - Nerlynx PA Policy | Policy |
| Oncology (Oral) - Nilotinib Products DQM Policy - Per Rx | Policy |
| Oncology (Oral) - Ojemda PA Policy | Policy |
| Oncology (Oral) - Pazopanib PSM Policy | Policy |
| Oncology (Oral) - Piqray PA Policy | Policy |
| Oncology (Oral) - Qinlock DQM Policy - Per Rx | Policy |
| Oncology (Oral) - Qinlock PA Policy | Policy |
| Oncology (Oral) - Scemblix DQM Policy - Per Rx | Policy |
| Oncology (Oral) - Sorafenib PSM Policy | Policy |
| Oncology (Oral) - Temozolomide Capsules PA Policy | Policy |
| Oncology (Oral) - Truqap PA Policy | Policy |
| Oncology (Oral) - Tukysa PA Policy | Policy |
| Oncology (Oral) - Turalio PA Policy | Policy |
| Oncology (Oral) - Veppanu PA Policy | Policy |
| Oncology (Oral) - Welireg PA Policy | Policy |
| Oncology (Oral) - Xermelo PA Policy | Policy |
| Oncology (Oral) - Xpovio PA Policy | Policy |
| Oncology (Oral) - Zydelig PA Policy | Policy |
| Oncology (Other) - Jelmyto PA Policy | Policy |
| Ophthalmic - Glaucoma - Alpha-Adrenergic Agonists Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Beta-Adrenergic Blockers Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Combination Products Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Prostaglandins PA Policy | Policy |
| Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy | Policy |
| Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy | Policy |
| Ophthalmic Corticosteroids Step Therapy Policy | Policy |
| Ophthalmic Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy | Policy |
| Ophthalmology - Dry Eye Disease - Cyclosporine Products PA | Policy |
| Ophthalmology - Dry Eye Disease - Eysuvis PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Lacrisert DQM Policy - Per Rx | Policy |
| Ophthalmology - Dry Eye Disease - Lacrisert PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Miebo PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Tryptyr PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Tyrvaya PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Xiidra PA Policy | Policy |
| Ophthalmology - Gene Therapy - Encelto PA Policy | Policy |
| Ophthalmology - Gene Therapy - Luxturna PA Policy | Policy |
| Ophthalmology - iDose TR PA Policy | Policy |
| Ophthalmology - Izervay PA Policy | Policy |
| Ophthalmology - Lumvoa PA Policy | Policy |
| Ophthalmology - Oxervate PA Policy | Policy |
| Ophthalmology - Syfovre PA Policy | Policy |
| Ophthalmology - Tepezza PA Policy | Policy |
| Ophthalmology - Upneeq PA Policy | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Aflibercept Products PA Policy | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Aflibercept Products PSM Policy | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu PA Policy | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Ranibizumab Products PSM Policy | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA Policy | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA Policy | Policy |