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.

Bone Modifiers - Denosumab Products (Prolia) PA Policy Policy
Bone Modifiers - Denosumab Products (Prolia) PA Policy-1 Policy
Bone Modifiers - Denosumab Products (Prolia) PA Policy-2 Policy
Bone Modifiers - Denosumab Products (Prolia) PA Policy-3 Policy
Bone Modifiers - Denosumab Products (Prolia) PA Policy-4 Policy
Bone Modifiers - Denosumab Products (Prolia) PA Policy-5 Policy
Bone Modifiers - Denosumab Products (Xgeva) PA Policy Policy
Bone Modifiers - Denosumab Products (Xgeva) PA Policy-1 Policy
Bone Modifiers - Denosumab Products (Xgeva) PA Policy-2 Policy
Bone Modifiers - Denosumab Products (Xgeva) PA Policy-3 Policy
Bone Modifiers - Denosumab Products (Xgeva) PA Policy-4 Policy
Bone Modifiers - Evenity PA Policy Policy
Bone Modifiers - Ibandronate Intravenous PA Policy Policy
Bone Modifiers - Teriparatide DQM Policy - Per Days Policy
Bone Modifiers - Teriparatide DQM Policy - Per Days-1 Policy
Bone Modifiers - Teriparatide DQM Policy - Per Days-2 Policy
Bone Modifiers - Teriparatide Products PA Policy Policy
Bone Modifiers - Teriparatide Products PA Policy-1 Policy
Bone Modifiers - Teriparatide Products PA Policy-2 Policy
Bone Modifiers - Teriparatide Products PA Policy-3 Policy
Bone Modifiers - Teriparatide Products PA Policy-4 Policy
Bone Modifiers - Tymlos PA Policy Policy
Bone Modifiers - Tymlos PA Policy-1 Policy
Bone Modifiers - Xgeva DQM Policy - Per Rx Policy
Bone Modifiers - Xgeva PA Policy Policy
Bone Modifiers - Zoledronic Acid (Reclast) PA Policy Policy
Bone Modifiers - Zoledronic Acid (Zometa) PA Policy Policy
Botulinum Toxins - Botox PA Policy Policy
Botulinum Toxins - Dysport PA Policy Policy
Botulinum Toxins - Myobloc PA Policy Policy
Botulinum Toxins - Xeomin PA Policy Policy
Bowel Agents - Chronic Idiopathic Constipation and Irritable Bowel Syndrome with Constipation Preferred Step Therapy Policy Policy
Bowel Agents - Lubiprostone DQM Policy - Per Rx Policy
Cabergoline DQM Policy - Per Days Policy
Calcitonin Gene-Related Peptide Inhibitors - Aimovig DQM Policy - Per Days Policy
Calcitonin Gene-Related Peptide Inhibitors - Emgality DQM Policy - Per Days Policy
Calcium Channel Blockers-Dihydropyridine Products Step Therapy Policy Policy
Calcium Channel Blockers-Verapamil Products Step Therapy Policy Policy
Calcium Channel Blockers-Verapamil Products Step Therapy Policy-1 Policy
Carbinoxamine Step Therapy Policy Policy
Carbinoxamine Step Therapy Policy-1 Policy
Cardiology - Camzyos PA Policy Policy
Cardiology - Camzyos PA Policy-1 Policy
Cardiology - Camzyos PA Policy-2 Policy
Cardiology - Ivabradine PA Policy Policy
Cardiology - Ranolazine Products Step Therapy Policy Policy
Cardiology - Verquvo DQM Policy - Per Rx Policy
Cardiology - Zontivity PA Policy Policy
Chelating Agents - Chemet PA Policy Policy
Chelating Agents - Iron Chelators (Oral) PA Policy Policy
Chelating Agents - Iron Chelators (Oral) PSM Policy Policy
Chelating Agents - Trientine Products PA Policy Policy
Chenodiol Products PA Policy Policy
Cholbam PA Policy Policy
Chorionic Gonadotropins DQM Policy - Per Rx Policy
Chorionic Gonadotropins PSM Policy (Effective 7.1.2025) Policy
Cinacalcet PA Policy
Colchicine Products Preferred Step Therapy Policy Policy
Colony Stimulating Factors - Filgrastim Products PA Policy Policy
Colony Stimulating Factors - Filgrastim Products PA Policy-1 Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for Basic Formulary Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for Basic Formulary-1 Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for Flex, High Performance, and National Preferred Formularies Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for Flex, High Performance, and National Preferred Formularies-1 Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for High Performance and National Preferred Formularies Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for High Performance and National Preferred Formularies-1 Policy
Colony Stimulating Factors - Granix PA Policy Policy
Colony Stimulating Factors - Leukine PA Policy Policy
Colony Stimulating Factors - Pegfilgrastim Products and Rolvedon PSM Policy For High Performance and National Preferred Formularies Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy-1 Policy
Colony Stimulating Factors - Pegfilgrastim Products, Rolvedon and Ryzneuta PSM Policy For High Performance and National Preferred Formularies Policy
Colony Stimulating Factors - Rolvedon PA Policy Policy
Complement Inhibitors - Eculizumab Products PA Policy Policy
Complement Inhibitors - Empaveli PA Policy Policy
Complement Inhibitors - Empaveli PA Policy-1 Policy
Complement Inhibitors - Empaveli PA Policy-2 Policy
Complement Inhibitors - Empaveli PA Policy-3 Policy
Complement Inhibitors - Fabhalta PA Policy Policy
Complement Inhibitors - Soliris PA Policy Policy
Complement Inhibitors - Ultomiris PA Policy Policy
Complement Inhibitors - Ultomiris PA Policy-1 Policy
Contraceptives - Oral, Patch, and Vaginal Ring Products Step Therapy Policy Policy
Contraceptives - Oral, Patch, and Vaginal Ring Products Step Therapy Policy-1 Policy
Contraceptives - Phexx PA Policy Policy
Contraceptives - Phexx PA Policy-1 Policy
Coronavirus - Oral Medications for Treatment of COVID-19 DQM Policy - Per Days Policy
Coronavirus - Oral Medications for Treatment of COVID-19 DQM Policy - Per Days-1 Policy
Coronavirus Disease - Evusheld PA Policy Policy
Coronavirus Disease - Veklury PA Policy Policy
Corticosteroids (Intraarticular) - Zilretta PA Policy Policy
Corticosteroids (Nasal) - Mometasone DQM Policy - Per Rx Policy
Corticosteroids (Nebulized) - Budesonide DQM Policy - Per Rx Policy
Crysvita PA Policy Policy
Crysvita PA Policy-1 Policy
Cushing's - Isturisa PA Policy Policy
Cushing's - Isturisa PA Policy-1 Policy
Cushing's - Mifepristone PA Policy Policy
Cushing's - Recorlev PA Policy Policy
Cushing's - Signifor PA Policy Policy
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