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.

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 PA Policy-1 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 PA Policy Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy Policy
Pulmonary Arterial Hypertension - Treprostinil Injection PA Policy Policy
Pulmonary Arterial Hypertension - Treprostinil Injection PSM Policy Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy-1 Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy-2 Policy
Repository Corticotropin - Acthar Gel PA Policy Policy
Repository Corticotropin - Cortrophin Gel PA Policy Policy
Rituximab Intravenous Products PA Policy Policy
Rituximab Intravenous Products PA Policy-1 Policy
Rituximab Intravenous Products PA Policy-2 Policy
Rituximab Intravenous Products PA Policy-3 Policy
Rituximab Intravenous Products PA Policy-4 Policy
Rituximab Intravenous Products PSM 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 PA Policy Policy
Sickle Cell Disease - Oxbryta PA Policy Policy
Somatostatin Analogs - Mycapssa PA Policy Policy
Somatostatin Analogs - Octreotide Immediate-Release Products PA Policy Policy
Somatostatin Analogs - Octreotide Immediate-Release Products PA Policy-1 Policy
Somatostatin Analogs - Octreotide Immediate-Release Products PSM Policy Policy
Somatostatin Analogs - Octreotide Long-Acting Products PA Policy Policy
Somatostatin Analogs - Octreotide Long-Acting Products PA Policy-1 Policy
Somatostatin Analogs - Signifor LAR PA Policy Policy
Somatostatin Analogs – Octreotide Immediate-Release Products PA Policy Policy
Somatostatin Analogs – Octreotide Long-Acting Products PA Policy Policy
Somatostatin Analogs for Acromegaly PSM Policy Policy
Somavert PA Policy Policy
Spinal Muscular Atrophy - Evrysdi PA Policy Policy
Spinal Muscular Atrophy - Evrysdi PA Policy-1 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
Synagis PA Policy Policy
Tasimelteon Products PA Policy Policy
Testosterone (injectable) Products PA Policy Policy
Testosterone Products (Topical) DQM Policy - Per Rx Policy
Tetracyclines (Oral) Step Therapy Policy Policy
Tetracyclines (Oral) Step Therapy Policy-1 Policy
Thrombocytopenia - Doptelet DQM Policy - Per Rx Policy
Thrombocytopenia - Doptelet DQM Policy - Per Rx-1 Policy
Thrombocytopenia - Doptelet PA Policy Policy
Thrombocytopenia - Doptelet PA Policy-1 Policy
Thrombocytopenia - Doptelet PA Policy-2 Policy
Thrombocytopenia - Eltrombopag Products PA Policy Policy
Thrombocytopenia - Eltrombopag Products PA Policy-1 Policy
Thrombocytopenia - Eltrombopag Products PA Policy-2 Policy
Thrombocytopenia - Mulpleta PA Policy Policy
Thrombocytopenia - Nplate PA Policy Policy
Thrombocytopenia - Tavalisse PA Policy Policy
Tolvaptan Products - Tolvaptan (Jynarque) PA Policy Policy
Tolvaptan Products - Tolvaptan (Jynarque) PA Policy-1 Policy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy Policy
Tolvaptan Products DQM Policy - Per Rx Policy
Topical Acne - Cleansers Step Therapy Policy Policy
Topical Acne - Cleansers Step Therapy Policy-1 Policy
Topical Acne - Cleansers Step Therapy Policy-2 Policy
Topical Acne - Cleansers Step Therapy Policy-3 Policy
Topical Acne - Kits Step Therapy Policy Policy
Topical Acne - Kits Step Therapy Policy-1 Policy
Topical Acne - Winlevi PA Policy Policy
Topical Acne Products Step Therapy Policy Policy
Topical Acne Products Step Therapy Policy-1 Policy
Topical Acne Products Step Therapy Policy-2 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 Anesthetics DQM Policy - Per Days Policy
Topical Anesthetics DQM Policy - Per Days-1 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 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 Corticosteroids Step Therapy Policy-1 Policy
Topical Diclofenac Sodium 3 percent Gel PA Policy Policy
Topical Doxepin Step Therapy Policy Policy
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