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.

Synagis PA 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 DQM Policy - Per Rx	Policy
Topical Acne - Cleansers Step Therapy Policy	Policy
Topical Acne - Kits Step Therapy Policy	Policy
Topical Acne - Winlevi PA Policy	Policy
Topical Acne Products Step Therapy Policy	Policy
Topical Acyclovir Products PA with Step Therapy Policy	Policy
Topical Agents for Atopic Dermatitis DQM Policy - Per Days	Policy
Topical Agents for Atopic Dermatitis Step Therapy Policy	Policy
Topical Alpha-Adrenergic Agonists for Rosacea - Brimonidine PA Policy	Policy
Topical Alpha-Adrenergic Agonists for Rosacea - Rhofade PA Policy	Policy
Topical Anesthetic - Lidocaine,Tetracaine Products PA with Step Therapy Policy	Policy
Topical Anesthetics DQM Policy - Per Days	Policy
Topical Antibacterials Step Therapy Policy	Policy
Topical Antibiotics for Acne - Clindamycin DQM Policy - Per Days	Policy
Topical Antifungals DQM Policy – Per Days	Policy
Topical Antifungals for Onychomycosis Step Therapy Policy	Policy
Topical Antifungals for Seborrheic Dermatitis Step Therapy	Policy
Topical Antipruritics - Doxepin Products DQM Policy - Per Days	Policy
Topical Calcipotriene Products DQM Policy - Per Days	Policy
Topical Collagenase - Santyl DQM Policy - Per Rx	Policy
Topical Corticosteroids - Clobetasol DQM Policy - Per Days	Policy
Topical Corticosteroids - Diflorasone DQM Policy - Per Days	Policy
Topical Corticosteroids - Fluocinonide DQM Policy - Per Days	Policy
Topical Corticosteroids - Flurandrenolide DQM Policy - Per Days	Policy
Topical Corticosteroids - Hydrocortisone Butyrate DQM Policy - Per Days	Policy
Topical Corticosteroids - Triamcinolone Topical Spray DQM Policy - Per Days	Policy
Topical Corticosteroids Step Therapy Policy	Policy
Topical Diclofenac Sodium 3 percent Gel PA Policy	Policy
Topical Doxepin Step Therapy Policy	Policy
Topical Medications for Inflammatory Rosacea Step Therapy	Policy
Topical Nonsteroidal Anti-Inflammatory Drugs - Diclofenac DQM Policy - Per Days	Policy
Topical Podofilox Products Step Therapy Policy	Policy
Topical Products - Vtama and Zoryve 0.3% Cream Step Therapy Policy	Policy
Topical Products - Zoryve Foam Step Therapy Policy	Policy
Topical Retinoids - Aklief PA Policy	Policy
Topical Retinoids - Panretin PA Policy	Policy
Topical Retinoids - Tazarotene Products PA Policy	Policy
Topical Vitamin D Analogs Step Therapy Policy	Policy
Transplantation - Grafapex PA Policy	Policy
Transplantation - Yartemlea PA Policy	Policy
Uplizna PA Policy	Policy
Vecamyl PA Policy	Policy
Veregen PA Policy	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors DQM Policy - Per Rx	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy	Policy
Vijoice PA Policy	Policy
Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy	Policy
Vitamin D Analog (Oral) Step Therapy Policy	Policy
Wakefulness-Promoting Agents - Armodafinil, Modafinil PA with Step Therapy Policy	Policy
Wakefulness-Promoting Agents - Sunosi DQM Policy - Per Rx	Policy
Wakefulness-Promoting Agents - Sunosi PA with Step Therapy Policy	Policy
Wakefulness-Promoting Agents - Wakix DQM Policy - Per Rx	Policy
Wakefulness-Promoting Agents - Wakix PA with Step Therapy Policy	Policy
Weight Loss - Appetite Suppressants and Orlistat PA Policy	Policy
Xiaflex PA Policy	Policy
Zokinvy PA Policy	Policy

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