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 (Injectable - Programmed Death Receptor-1) - Keytruda PA Policy-3 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Libtayo PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Libtayo PA Policy-1 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Libtayo PA Policy-2 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy-1 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy-2 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy-3 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy-4 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdualag PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Zynyz PA Policy | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Zynyz PA Policy-1 | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Zynyz PA Policy-2 | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Bavencio PA Policy | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Imfinzi PA Policy | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Imfinzi PA Policy-1 | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Imfinzi PA Policy-2 | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Imfinzi PA Policy-3 | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq PA Policy | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq PA Policy-1 | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq PA Policy-2 | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq PA Policy-3 | Policy |
| Oncology (Injectable - Proteasome Inhibitor) - Bortezomib Products PA Policy | Policy |
| Oncology (Injectable - Proteasome Inhibitor) - Bortezomib Products PA Policy-1 | Policy |
| Oncology (Injectable - Proteasome Inhibitor) - Kyprolis PA Policy | Policy |
| Oncology (Injectable - Proteasome Inhibitor) - Kyprolis PA Policy-1 | Policy |
| Oncology (Injectable - Topoisomerase Inhibitor) - Onivyde PA Policy | Policy |
| Oncology (Injectable - Topoisomerase Inhibitor) - Topotecan Products PA Policy | Policy |
| Oncology (Injectable) - Adcetris PA Policy | Policy |
| Oncology (Injectable) - Asparlas PA Policy | Policy |
| Oncology (Injectable) - Azedra PA Policy | Policy |
| Oncology (Injectable) - Bendamustine Products PA Policy | Policy |
| Oncology (Injectable) - Besremi PA Policy | Policy |
| Oncology (Injectable) - Bevacizumab Products PA Policy | Policy |
| Oncology (Injectable) - Bevacizumab Products PA Policy-1 | Policy |
| Oncology (Injectable) - Bevacizumab Products PSM Policy | Policy |
| Oncology (Injectable) - Bevacizumab Products PSM Policy-1 | Policy |
| Oncology (Injectable) - Blenrep PA Policy | Policy |
| Oncology (Injectable) - Blincyto PA Policy | Policy |
| Oncology (Injectable) - Carmustine Products PA Policy | Policy |
| Oncology (Injectable) - Cosela PA Policy | Policy |
| Oncology (Injectable) - Cyramza PA Policy | Policy |
| Oncology (Injectable) - Danyelza PA Policy | Policy |
| Oncology (Injectable) - Decitabine Products PA Policy | Policy |
| Oncology (Injectable) - Elahere PA Policy | Policy |
| Oncology (Injectable) - Elzonris PA Policy | Policy |
| Oncology (Injectable) - Empliciti PA Policy | Policy |
| Oncology (Injectable) - Enhertu PA Policy | Policy |
| Oncology (Injectable) - Erbitux PA Policy | Policy |
| Oncology (Injectable) - Fulvestrant PA Policy | Policy |
| Oncology (Injectable) - Fyarro PA Policy | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy-1 | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy-2 | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy-1 | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy-2 | Policy |
| Oncology (Injectable) - Halaven PA Policy | Policy |
| Oncology (Injectable) - Herceptin Hylecta PA Policy | Policy |
| Oncology (Injectable) - Imlygic PA Policy | Policy |
| Oncology (Injectable) - Ixempra PA Policy | Policy |
| Oncology (Injectable) - Jevtana PA Policy | Policy |
| Oncology (Injectable) - Kimmtrak PA Policy | Policy |
| Oncology (Injectable) - Levoleucovorin Products PA Policy | Policy |
| Oncology (Injectable) - Lunsumio PA Policy | Policy |
| Oncology (Injectable) - Margenza PA Policy | Policy |
| Oncology (Injectable) - Mylotarg PA Policy | Policy |
| Oncology (Injectable) - Onivyde PA Policy | Policy |
| Oncology (Injectable) - Padcev PA Policy | Policy |
| Oncology (Injectable) - Polivy PA Policy | Policy |
| Oncology (Injectable) - Portrazza PA Policy | Policy |
| Oncology (Injectable) - Poteligeo PA Policy | Policy |
| Oncology (Injectable) - Pralatrexate Products PA Policy | Policy |
| Oncology (Injectable) - Proleukin PA Policy | Policy |
| Oncology (Injectable) - Rituxan Hycela PA Policy | Policy |
| Oncology (Injectable) - Rybrevant PA Policy | Policy |
| Oncology (Injectable) - Rylaze PA Policy | Policy |
| Oncology (Injectable) - Sylvant PA Policy | Policy |
| Oncology (Injectable) - Sylvant PA Policy-1 | Policy |
| Oncology (Injectable) - Sylvant PA Policy-2 | Policy |
| Oncology (Injectable) - Thiotepa Products PA Policy | Policy |
| Oncology (Injectable) - Tivdak PA Policy | Policy |
| Oncology (Injectable) - Topotecan Products PA Policy | Policy |
| Oncology (Injectable) - Trastuzumab Products PSM Policy | Policy |
| Oncology (Injectable) - Trastuzumab Products PSM Policy-1 | Policy |
| Oncology (Injectable) - Trastuzumab Products PSM Policy-2 | Policy |
| Oncology (Injectable) - Trodelvy PA Policy | Policy |
| Oncology (Injectable) - Unituxin PA Policy | Policy |
| Oncology (Injectable) - Vectibix PA Policy | Policy |
| Oncology (Injectable) - Vyxeos PA Policy | Policy |
| Oncology (Injectable) - Zepzelca PA Policy | Policy |
| Oncology (Injectable) - Zynlonta PA Policy | Policy |
| Oncology (Intravesical) - Valrubicin Products PA Policy | Policy |
| Oncology (Intravesical) - Valrubicin Products PA Policy-1 | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alecensa PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alecensa PA Policy-1 | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alunbrig PA Policy | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alunbrig PA Policy-1 | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alunbrig PA Policy-2 | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Ensacove PA Policy | Policy |