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.

Infectious Disease - Vancomycin (Oral) DQM Policy - Per Rx Policy
Infectious Disease - Xifaxan DQM Policy - Per Rx Policy
Infertility - Follitropins, Clomiphene PSM policy Policy
Infertility - Gonadotropin-Releasing Hormone Antagonists PSM Policy Policy
Inflammatory Conditions - Adalimumab Products Care Value Policy for High Performance Formulary Policy
Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days Policy
Inflammatory Conditions - Adalimumab Products PSM Policy for High Performance Formulary Policy
Inflammatory Conditions - Arcalyst DQM Policy - Per Days Policy
Inflammatory Conditions - Bimzelx DQM Policy - Per Days Policy
Inflammatory Conditions - Cibinqo PA Policy Policy
Inflammatory Conditions - Cosentyx Subcutaneous DQM Policy - Per Days Policy
Inflammatory Conditions - Etanercept Products DQM Policy - Per Days Policy
Inflammatory Conditions - Ilaris DQM Policy - Per Days Policy
Inflammatory Conditions - Ilumya DQM Policy - Per Days Policy
Inflammatory Conditions - Kineret DQM Policy - Per Days Policy
Inflammatory Conditions - Leqselvi PA Policy Policy
Inflammatory Conditions - Litfulo PA Policy Policy
Inflammatory Conditions - Otezla DQM Policy - Per Days Policy
Inflammatory Conditions - Rinvoq DQM Policy - Per Days Policy
Inflammatory Conditions - Siliq DQM Policy - Per Days Policy
Inflammatory Conditions - Simponi Subcutaneous DQM Policy - Per Days Policy
Inflammatory Conditions - Spevigo Intravenous PA Policy Policy
Inflammatory Conditions - Spevigo Subcutaneous PA Policy Policy
Inflammatory Conditions - Taltz DQM Policy - Per Days Policy
Inflammatory Conditions - Tocilizumab Intravenous Products PA Policy Policy
Inflammatory Conditions - Tocilizumab Subcutaneous Products PA Policy Policy
Inflammatory Conditions - Tremfya Subcutaneous DQM Policy - Per Days Policy
Inflammatory Conditions - Ustekinumab Subcutaneous DQM Policy - Per Days Policy
Inflammatory Conditions - Ustekinumab Subcutaneous Products Care Value Policy for High Performance Formulary Policy
Inflammatory Conditions - Ustekinumab Subcutaneous Products PSM Policy for High Performance Formulary Policy
Inflammatory Conditions - Zymfentra DQM Policy - Per Days Policy
Inflammatory Conditions Care Value Policy for High Performance Formulary Policy
Inflammatory Conditions PSM Policy for High Performance Formulary Policy
Inpefa PA Policy Policy
Interferon - Actimmune PA Policy Policy
Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy Policy
Iron Replacement – Ferumoxytol PA Policy Policy
Iron Replacement – INFeD PA Policy Policy
Iron Replacement – Injectafer PA Policy Policy
Iron Replacement – Iron Sucrose PA Policy Policy
Iron Replacement – Monoferric PA Policy Policy
Iron Replacement – Sodium Ferric Gluconate PA Policy Policy
Isotretinoin Step Therapy Policy Policy
Kygevvi PA Policy Policy
Levothyroxine Products Step Therapy Policy Policy
Lidocaine Patch Products PA Policy Policy
Lipodystrophy - Egrifta PA Policy Policy
Lipodystrophy - Myalept PA Policy Policy
Lofexidine PA Policy Policy
Lupus - Benlysta Intravenous PA Policy Policy
Lupus - Benlysta Subcutaneous DQM Policy - Per Days Policy
Lupus - Benlysta Subcutaneous PA Policy Policy
Lupus - Lupkynis PA Policy Policy
Lupus - Saphnelo PA Policy Policy
Menkes Disease - Zycubo PA Policy Policy
Metabolic Disorders - Betaine Anhydrous PA Policy Policy
Metabolic Disorders - Betaine Anhydrous PSM Policy Policy
Metabolic Disorders - Carglumic Acid PA Policy Policy
Metabolic Disorders - Dojolvi PA Policy Policy
Metabolic Disorders - Imcivree PA Policy Policy
Metabolic Disorders - Nitisinone Products PA Policy Policy
Metabolic Disorders - Nulibry PA Policy Policy
Metabolic Disorders - Phenylbutyrate Products PSM Policy Policy
Metabolic Disorders - Primary Hyperoxaluria - Oxlumo PA Policy Policy
Metabolic Disorders - Primary Hyperoxaluria - Rivfloza PA Policy Policy
Metabolic Disorders - Tiopronin Products PSM Policy Policy
Metabolic Disorders - Xuriden PA Policy Policy
Metabolic Disorders – Cysteamine Ophthalmic Solution PA Policy Policy
Methotrexate Injection Step Therapy Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality DQM Policy - Per Days Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Vyepti PA Policy Policy
Migraine - Elyxyb PA Policy Policy
Migraine - Nurtec ODT PA Policy Policy
Migraine - Qulipta PA Policy Policy
Migraine - Reyvow PA Policy Policy
Migraine - Ubrelvy PA Policy Policy
Migraine - Zavzpret PA Policy Policy
Migraine – Nonsteroidal Anti-Inflammatory Drugs DQM Policy – Per Days Policy
Migraine – Other Medications DQM Policy – Per Days Policy
Migraine – Triptans DQM Policy – Per Days Policy
Migraine Medication Step Therapy Policy Policy
Multiple Sclerosis - CD20-Directed Cytolytic Antibody Infused Products PSM Policy Policy
Multiple Sclerosis - Dalfampridine PSM Policy Policy
Multiple Sclerosis - Kesimpta DQM Policy - Per Days Policy
Multiple Sclerosis - Lemtrada DQM Policy - Per Days Policy
Multiple Sclerosis - Ocrevus and Ocrevus Zunovo DQM Policy - Per Days Policy
Multiple Sclerosis - Ponvory DQM Policy - Per Days Policy
Multiple Sclerosis (Injectable - Other) - Lemtrada PA Policy Policy
Multiple Sclerosis (Oral - Fumarate) - Dimethyl Fumarate PA Policy Policy
Multiple Sclerosis (Oral - Other) - Teriflunomide PA Policy Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM Policy for High Performance Formulary 01.01.26 Policy
Multiple Sclerosis PSM Policy Policy
Muscular Dystrophy - Agamree PA Policy Policy
Muscular Dystrophy - Amondys 45 PA Policy Policy
Muscular Dystrophy - Deflazacort PA Policy Policy
Muscular Dystrophy - Deflazacort PSM Policy Policy
Muscular Dystrophy - Duvyzat PA Policy Policy
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