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.

Cushing's Disease - Isturisa DQM Policy - Per Rx Policy
Cystic Fibrosis - Bronchitol PA Policy Policy
Cystic Fibrosis - Pulmozyme PA Policy Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Kalydeco PA Policy Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Kalydeco PA Policy-1 Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Orkambi PA Policy Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Orkambi PA Policy-1 Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Symdeko PA Policy Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Symdeko PA Policy-1 Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Trikafta PA Policy Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Trikafta PA Policy-1 Policy
Dermatology - Hyftor PA Policy
Dermatology - Opzelura PA Policy Policy
Dermatology - Opzelura PA Policy-1 Policy
Dermatology - Vtama DQM Policy - Per Days Policy
Dermatology - Zoryve DQM Policy - Per Days Policy
Desmopressin Products - Nocdurna PA Policy Policy
Diabetes - Canagliflozin Products DQM Policy - Per Rx Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy-1 Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy-2 Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy-1 Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy-1 Policy
Diabetes - Metformin Extended-Release DQM Policy - Per Rx Policy
Diabetes - Metformin Step Therapy Policy Policy
Diabetes - Omnipod Pods DQM Policy - Per Days Policy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy Policy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy-1 Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy-1 Policy
Diabetes - Symlin PA Policy Policy
Diabetes - Tzield PA Policy Policy
Diuretics - Loop Products Step Therapy Policy Policy
Droxidopa PA Policy Policy
Enzyme Replacement Therapy - Aldurazyme PA Policy Policy
Enzyme Replacement Therapy - Elaprase PA Policy Policy
Enzyme Replacement Therapy - Fabrazyme PA Policy Policy
Enzyme Replacement Therapy - Kanuma PA Policy Policy
Enzyme Replacement Therapy - Lamzede PA Policy Policy
Enzyme Replacement Therapy - Mepsevii PA Policy Policy
Enzyme Replacement Therapy - Naglazyme PA Policy Policy
Enzyme Replacement Therapy - Revcovi PA Policy Policy
Enzyme Replacement Therapy - Strensiq PA Policy Policy
Enzyme Replacement Therapy - Sucraid PA Policy Policy
Enzyme Replacement Therapy - Vimizim PA Policy Policy
Enzyme Replacement Therapy - Xenpozyme PA Policy Policy
Epinephrine Auto-Injectors Preferred Step Therapy Policy Policy
Epinephrine Auto-Injectors Step Therapy Policy Policy
Erectile Dysfunction - Alprostadil Products PA Policy Policy
Erectile Dysfunction - Avanafil PA Policy Policy
Erectile Dysfunction - Sildenafil PA Policy Policy
Erectile Dysfunction - Tadalafil PA Policy Policy
Erectile Dysfunction - Vardenafil PA Policy Policy
Erectile Dysfunction Agents DQM Policy - Per Days Policy
Erectile Dysfunction Agents DQM Policy - Per Days-1 Policy
Erectile Dysfunction Agents DQM Policy - Per Rx Policy
Erectile Dysfunction Agents DQM Policy - Per Rx-1 Policy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy Policy
Erythropoiesis-Stimulating Agents - Mircera PA Policy Policy
Erythropoiesis-Stimulating Agents - Mircera PA Policy-1 Policy
Erythropoiesis-Stimulating Agents PSM Policy for High Performance and National Preferred Formularies Policy
Estrogens (Topical) - Estradiol Gel DQM Policy - Per Rx Policy
Estrogens (Topical) - Patches DQM Policy - Per Days Policy
Fabry Disease - Galafold PA Policy Policy
Gabapentin Step Therapy Policy Policy
Gamifant PA Policy Policy
Gamifant PA Policy-1 Policy
Gastroenterology - Eohilia DQM Policy - Per Days Policy
Gastroenterology - Eohilia PA Policy Policy
Gastroenterology - Gattex PA Policy Policy
Gaucher Disease - Enzyme Replacement Therapy - Cerezyme PA Policy Policy
Gaucher Disease - Enzyme Replacement Therapy - Elelyso PA Policy Policy
Gaucher Disease - Enzyme Replacement Therapy - Vpriv PA Policy Policy
Gaucher Disease - Substrate Reduction Therapy - Cerdelga PA Policy Policy
Gaucher Disease - Substrate Reduction Therapy - Miglustat PA Policy Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy Policy
Gonadotropin-Releasing Hormone Agonists - Implants PA Policy Policy
Gonadotropin-Releasing Hormone Agonists - Lupron Depot PA Policy Policy
Gonadotropin-Releasing Hormone Antagonists - Myfembree PA Policy Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa DQM Policy - Per Rx and Per Days Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy Policy
Gout - Krystexxa PA Policy Policy
Gout Medications Step Therapy Policy Policy
Graft Versus-Host Disease - Rezurock DQM Policy - Per Rx Policy
Graft-Versus-Host Disease - Rezurock PA Policy Policy
Growth Disorders - Growth Hormone PA Policy Policy
Growth Disorders - Growth Hormone PA Policy-1 Policy
Growth Disorders - Growth Hormone PA Policy-2 Policy
Growth Disorders - Growth Hormone Short-Acting Products PSM Policy Policy
Growth Disorders - Increlex PA Policy Policy
Growth Disorders - Skytrofa PA Policy Policy
Growth Disorders - Skytrofa PA Policy-1 Policy
Growth Disorders - Skytrofa PA Policy-2 Policy
Growth Disorders - Skytrofa PA Policy-3 Policy
Growth Disorders - Voxzogo PA Policy Policy
Hematology - Cablivi PA Policy Policy
Hematology - Ceprotin PA Policy Policy
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