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 - Sunitinib PA Policy | Policy |
| Oncology - Sunitinib PSM Policy | Policy |
| Oncology - Tabrecta PA Policy | Policy |
| Oncology - Tagrisso PA Policy | Policy |
| Oncology - Talzenna PA Policy | Policy |
| Oncology - Tasigna DQM Policy - Per Rx | Policy |
| Oncology - Tazverik PA Policy | Policy |
| Oncology - Temozolomide Capsules PA Policy | Policy |
| Oncology - Tepmetko PA Policy | Policy |
| Oncology - Tibsovo PA Policy | Policy |
| Oncology - Tukysa PA Policy | Policy |
| Oncology - Turalio PA Policy | Policy |
| Oncology - Valchlor PA Policy | Policy |
| Oncology - Valchlor PA Policy-1 | Policy |
| Oncology - Venclexta DQM policy - Per Rx | Policy |
| Oncology - Venclexta PA Policy | Policy |
| Oncology - Verzenio PA Policy | Policy |
| Oncology - Vistogard DQM Policy - Per Rx | Policy |
| Oncology - Vistogard PA Policy | Policy |
| Oncology - Vitrakvi DQM Policy - Per Rx | Policy |
| Oncology - Vitrakvi DQM Policy - Per Rx-1 | Policy |
| Oncology - Vitrakvi PA Policy | Policy |
| Oncology - Welireg PA Policy | Policy |
| Oncology - Welireg PA Policy-1 | Policy |
| Oncology - Xalkori PA Policy | Policy |
| Oncology - Xermelo DQM Policy - Per Rx | Policy |
| Oncology - Xermelo PA Policy | Policy |
| Oncology - Xospata PA Policy | Policy |
| Oncology - Xpovio PA Policy | Policy |
| Oncology - Xtandi PA Policy | Policy |
| Oncology - Zejula PA Policy | Policy |
| Oncology - Zolinza PA Policy | Policy |
| Oncology - Zydelig PA Policy | Policy |
| Oncology (Injectable - Anti-GD2 Antibody) - Danyelza PA Policy | Policy |
| Oncology (Injectable - Anti-GD2 Antibody) - Unituxin PA Policy | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate - CD19) - Monjuvi PA Policy | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate - CD22) - Besponsa PA Policy | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate - HER2) - Kadcyla PA Policy | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate - HER2) - Kadcyla PA Policy-1 | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate - HER2) - Kadcyla PA Policy-2 | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate – HER2) - Enhertu PA Policy | Policy |
| Oncology (Injectable - Antibody-Drug Conjugate – Trop-2) - Trodelvy PA Policy | Policy |
| Oncology (Injectable - Asparaginase) - Asparlas PA Policy | Policy |
| Oncology (Injectable - Asparaginase) - Oncaspar PA Policy | Policy |
| Oncology (Injectable - Asparaginase) - Oncaspar PA Policy-1 | Policy |
| Oncology (Injectable - Asparaginase) - Rylaze PA Policy | Policy |
| Oncology (Injectable - Bispecific - BCMA-Directed) - Tecvayli PA Policy | Policy |
| Oncology (Injectable - Bispecific - BCMA-Directed) - Tecvayli PA Policy-1 | Policy |
| Oncology (Injectable - Bispecific - CD20-Directed) - Lunsumio PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Abecma PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Breyanzi PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Breyanzi PA Policy-1 | Policy |
| Oncology (Injectable - CAR-T) - Carvykti PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Kymriah PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Tecartus PA Policy | Policy |
| Oncology (Injectable - CAR-T) - Yescarta PA Policy | Policy |
| Oncology (Injectable - CD20-Directed Antibody) - Gazyva PA Policy | Policy |
| Oncology (Injectable - CD20-Directed Antibody) - Gazyva PA Policy-1 | Policy |
| Oncology (Injectable - CD20-Directed Antibody) - Gazyva PA Policy-2 | Policy |
| Oncology (Injectable - CD20-Directed Antibody) - Rituxan Hycela PA Policy | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Faspro PA Policy | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Faspro PA Policy-1 | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Faspro PA Policy-2 | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Faspro PA Policy-3 | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Intravenous PA Policy | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Intravenous PA Policy-1 | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Darzalex Intravenous PA Policy-2 | Policy |
| Oncology (Injectable - CD38-Directed Cytolytic Antibody) - Sarclisa PA Policy | Policy |
| Oncology (Injectable - CTLA-4 Antibody) - Imjudo PA Policy | Policy |
| Oncology (Injectable - CTLA-4 Antibody) - Imjudo PA Policy-1 | Policy |
| Oncology (Injectable - CTLA-4 Antibody) - Yervoy PA Policy | Policy |
| Oncology (Injectable - CTLA-4 Antibody) - Yervoy PA Policy-1 | Policy |
| Oncology (Injectable - CTLA-4 Antibody) - Yervoy PA Policy-2 | Policy |
| Oncology (Injectable - EGFR Antagonist) - Erbitux PA Policy | Policy |
| Oncology (Injectable - EGFR Antagonist) - Vectibix PA Policy | Policy |
| Oncology (Injectable - Epidermal Growth Factor Receptor Exon 20 Mutation Agent) - Rybrevant PA Policy | Policy |
| Oncology (Injectable - Epidermal Growth Factor Receptor Inhibitor) - Erbitux PA Policy | Policy |
| Oncology (Injectable - Epidermal Growth Factor Receptor Inhibitor) - Erbitux PA Policy-1 | Policy |
| Oncology (Injectable - Epidermal Growth Factor Receptor Inhibitor) - Vectibix PA Policy | Policy |
| Oncology (Injectable - Epidermal Growth Factor Receptor Inhibitor) - Vectibix PA Policy-1 | Policy |
| Oncology (Injectable - HER2 Antagonist) - Herceptin Hylecta PA Policy | Policy |
| Oncology (Injectable - HER2 Antagonist) - Perjeta PA Policy | Policy |
| Oncology (Injectable - HER2 Antagonist) - Phesgo PA Policy | Policy |
| Oncology (Injectable - HER2 Antagonist) - Trastuzumab Products PA Policy | Policy |
| Oncology (Injectable - HER2 Antagonist) - Trastuzumab Products PA Policy-1 | Policy |
| Oncology (Injectable - Histone Deacetylase Inhibitor) - Beleodaq PA Policy | Policy |
| Oncology (Injectable - Histone Deacetylase Inhibitor) - Beleodaq PA Policy-1 | Policy |
| Oncology (Injectable - Histone Deacetylase Inhibitor) - Romidepsin Products PA Policy | Policy |
| Oncology (Injectable - Histone Deacetylase Inhibitor) - Romidepsin Products PA Policy-1 | Policy |
| Oncology (Injectable - Microtubule Inhibitor) - Halaven PA Policy | Policy |
| Oncology (Injectable - Microtubule Inhibitor) - Ixempra PA Policy | Policy |
| Oncology (Injectable - Microtubule Inhibitor) - Jevtana PA Policy | Policy |
| Oncology (Injectable - mTOR Inhibitor) - Fyarro PA Policy | Policy |
| Oncology (Injectable - mTOR Inhibitor) - Torisel PA Policy | Policy |
| Oncology (Injectable - mTOR Inhibitor) - Torisel PA Policy-1 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Jemperli PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Jemperli PA Policy-1 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Keytruda PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Keytruda PA Policy-1 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Keytruda PA Policy-2 | Policy |