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.

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 - 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
Ophthalmology - Verkazia PA Policy	Policy
Opioids - Butorphanol DQM Policy - Per Days	Policy
Opioids - Fentanyl Transdermal Products DQM Policy - Per Days	Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy	Policy
Opioids - Fentanyl Transmucosal Products DQM Policy - Per Days	Policy
Opioids - Long-Acting Products (Oral) DQM Policy - Per Days	Policy
Opioids - Long-Acting Products PA Policy	Policy
Opioids - Methadone PA Policy	Policy
Opioids - Nucynta DQM Policy - Per Rx	Policy
Opioids - Tramadol Extended-Release Products DQM Policy - Per Rx	Policy
Opioids - Tramadol Extended-Release Products PA Policy	Policy
Overactive Bladder Medications Step Therapy Policy	Policy
Pain - Journavx DQM Policy - Per Days	Policy
Papillomatosis - Papzimeos PA Policy	Policy
Phenylketonuria - Palynziq DQM Policy - Per Rx	Policy
Phenylketonuria - Palynziq PA Policy	Policy
Phenylketonuria - Sapropterin PA Policy	Policy
Phenylketonuria - Sephience PA Policy	Policy
Pheochromocytoma - Metyrosine and Phenoxybenzamine (Oral) PA Policy	Policy
Phosphate Binders DQM Policy - Per Rx	Policy
Pompe Disease - Enzyme Replacement Therapy - Lumizyme PA Policy	Policy
Pompe Disease - Enzyme Replacement Therapy - Nexviazyme PA Policy	Policy
Pompe Disease - Enzyme Replacement Therapy - Pombiliti PA Policy	Policy
Pompe Disease - Enzyme Stabilization Therapy - Opfolda PA Policy	Policy
Potassium Binders - Lokelma DQM Policy - Per Rx	Policy
Potassium Binders - Veltassa DQM Policy - Per Rx	Policy
Prader-Willi Syndrome - Vykat XR PA Policy	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Repatha DQM Policy - Per Days	Policy
Proton Pump Inhibitors DQM Policy - Per Rx	Policy
Proton Pump Inhibitors Step Therapy Policy	Policy
Psychiatry - Novel Psychotropics DQM Policy - Per Rx	Policy
Psychiatry - Spravato PA Policy	Policy
Psychiatry - Zurzuvae PA Policy	Policy
Pulmonary - Antifibrotics - Jascayd PA Policy	Policy
Pulmonary - Antifibrotics - Ofev PA Policy	Policy
Pulmonary - Antifibrotics - Pirfenidone PSM Policy	Policy
Pulmonary - Brinsupri PA Policy	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers DQM Policy - Per Rx	Policy
Pulmonary - Roflumilast PA with Step Therapy Policy	Policy
Pulmonary Arterial Hypertension - Adempas DQM Policy - Per Rx	Policy
Pulmonary Arterial Hypertension - Adempas PA Policy	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PSM Policy	Policy
Pulmonary Arterial Hypertension - Orenitram DQM Policy - Per Rx	Policy
Pulmonary Arterial Hypertension - Orenitram PA Policy	Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy	Policy
Pulmonary Arterial Hypertension - Sildenafil DQM Policy - Per Rx	Policy
Pulmonary Arterial Hypertension - Treprostinil Injection PSM Policy	Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy	Policy
Pulmonary Arterial Hypertension - Winrevair PA Policy	Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy	Policy
Scenesse PA Policy	Policy
Sedative Hypnotics DQM Policy - Per Days	Policy
Sedative Hypnotics Step Therapy Policy	Policy
Sickle Cell Disease - Adakveo PA Policy	Policy
Sickle Cell Disease - Hydroxyurea Products Preferred Step Therapy Policy	Policy
Sickle Cell Disease - L-glutamine PSM Policy	Policy
Sohonos PA Policy	Policy
Somatostatin Analogs - Mycapssa DQM Policy - Per Days	Policy
Somatostatin Analogs - Mycapssa PA Policy	Policy
Somatostatin Analogs – Octreotide Immediate-Release Products PSM Policy	Policy
Somatostatin Analogs and Related Medications for Acromegaly PSM Policy	Policy
Somavert PA Policy	Policy
Spinal Muscular Atrophy - Evrysdi PA Policy	Policy
Spinal Muscular Atrophy - Gene Therapy - Itvisma PA Policy	Policy
Spinal Muscular Atrophy - Gene Therapy - Zolgensma PA Policy	Policy
Spinal Muscular Atrophy - Spinraza DQM Policy - Per Days	Policy
Spinal Muscular Atrophy - Spinraza PA Policy	Policy

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