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.

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 - Tapentadol 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
Parkinson's Disease - Amantadine Extended-Release Products PA with Step Therapy Policy Policy
Parkinson's Disease - Apomorphine Subcutaneous (Apokyn) PA Policy Policy
Parkinson's Disease - Carbidopa PA Policy Policy
Parkinson's Disease - Carbidopa-Levodopa (Oral) Step Therapy Policy Policy
Parkinson's Disease - Duopa PA Policy Policy
Parkinson's Disease - Inbrija PA Policy Policy
Parkinson's Disease - Kynmobi PA Policy Policy
Parkinson's Disease - Nourianz PA Policy Policy
Parkinson's Disease - Nuplazid PA Policy Policy
Parkinson's Disease - Onapgo PA Policy Policy
Parkinson's Disease - Ongentys PA Policy Policy
Parkinson's Disease - Tolcapone PA Policy Policy
Parkinson's Disease - Vyalev PA Policy Policy
Parkinson's Disease - Zelapar 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
Prednisone Delayed Release Products Step Therapy 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 - Nintedanib PA Policy Policy
Pulmonary - Antifibrotics PSM Policy Policy
Pulmonary - Brinsupri PA Policy Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers DQM Policy - Per Rx Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy 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 DQM Policy - Per Rx and Per Days Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy Policy
Repository Corticotropin - Acthar Gel PA Policy Policy
Repository Corticotropin - Cortrophin Gel 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
Statins Step Therapy Policy Policy
Tasimelteon Capsules PSM Policy Policy
Testosterone (injectable) Products PA Policy Policy
Testosterone (Oral, Topical, and Nasal) Products PA Policy Policy
Testosterone Products (Topical) DQM Policy - Per Rx Policy
Tetracyclines (Oral) Step Therapy Policy Policy
Thrombocytopenia - Doptelet PA Policy Policy
Thrombocytopenia - Eltrombopag Products PSM Policy
Thrombocytopenia - Mulpleta PA Policy Policy
Thrombocytopenia - Nplate PA Policy Policy
Thrombocytopenia - Tavalisse PA Policy Policy
Thrombocytopenia - Wayrilz PA Policy Policy
Tolvaptan Products - tolvaptan (Jynarque) PSM Policy Policy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy Policy
Tolvaptan Products DQM Policy - Per Rx Policy
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