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.
| Immunologicals - Adbry PA Policy | Policy |
| Immunologicals - Adbry PA Policy-1 | Policy |
| Immunologicals - Asthma PSM Policy | Policy |
| Immunologicals - Cinqair PA Policy | Policy |
| Immunologicals - Cinqair PA Policy-1 | Policy |
| Immunologicals - Cinqair PA Policy-2 | Policy |
| Immunologicals - Dupixent DQM Policy - Per Days | Policy |
| Immunologicals - Dupixent DQM Policy - Per Days-1 | Policy |
| Immunologicals - Dupixent PA Policy | Policy |
| Immunologicals - Dupixent PA Policy-1 | Policy |
| Immunologicals - Dupixent PA Policy-2 | Policy |
| Immunologicals - Dupixent PA Policy-3 | Policy |
| Immunologicals - Dupixent PA Policy-4 | Policy |
| Immunologicals - Dupixent PA Policy-5 | Policy |
| Immunologicals - Dupixent PA Policy-6 | Policy |
| Immunologicals - Fasenra DQM Policy - Per Days | Policy |
| Immunologicals - Fasenra DQM Policy - Per Days-1 | Policy |
| Immunologicals - Fasenra PA Policy | Policy |
| Immunologicals - Fasenra PA Policy-1 | Policy |
| Immunologicals - Nucala DQM Policy - Per Days | Policy |
| Immunologicals - Nucala PA Policy | Policy |
| Immunologicals - Nucala PA Policy-1 | Policy |
| Immunologicals - Nucala PA Policy-2 | Policy |
| Immunologicals - Nucala PA Policy-3 | Policy |
| Immunologicals - Tezspire PA Policy | Policy |
| Immunologicals - Tezspire PA Policy-1 | Policy |
| Immunologicals - Tezspire PA Policy-2 | Policy |
| Immunologicals - Tezspire PA Policy-3 | Policy |
| Immunologicals - Xolair DQM Policy - Per Days | Policy |
| Immunologicals - Xolair PA Policy | Policy |
| Immunologicals - Xolair PA Policy-1 | Policy |
| Immunologicals - Xolair PA Policy-2 | Policy |
| Immunologicals - Xolair PA Policy-3 | Policy |
| Infectious Disease - Impavido PA Policy | Policy |
| Infectious Disease - Ivermectin Tablets PA Policy | Policy |
| Infectious Disease - Livtencity DQM Policy - Per Days | Policy |
| Infectious Disease - Livtencity PA Policy | Policy |
| Infectious Disease - Pretomanid PA Policy | Policy |
| Infectious Disease - Pyrimethamine PA Policy | Policy |
| Infectious Disease - Pyrimethamine PA Policy-1 | Policy |
| Infectious Disease - Sirturo PA Policy | Policy |
| Infectious Disease - Sirturo PA Policy-1 | Policy |
| Infertility - Follitropins, Clomiphene PSM policy | Policy |
| Infertility - Follitropins, Clomiphene PSM policy-1 | Policy |
| Infertility - Gonadotropin-Releasing Hormone Antagonists PSM Policy | Policy |
| Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days-1 | Policy |
| Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days-2 | Policy |
| Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days-3 | Policy |
| Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days-4 | Policy |
| Inflammatory Conditions - Adalimumab Products PA Policy | Policy |
| Inflammatory Conditions - Adalimumab Products PA Policy-1 | Policy |
| Inflammatory Conditions - Adalimumab Products PA Policy-2 | Policy |
| Inflammatory Conditions - Adalimumab Products PA Policy-3 | Policy |
| Inflammatory Conditions - Arcalyst DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Arcalyst DQM Policy - Per Days-1 | Policy |
| Inflammatory Conditions - Arcalyst PA Policy | Policy |
| Inflammatory Conditions - Arcalyst PA Policy-1 | Policy |
| Inflammatory Conditions - Cibinqo PA Policy | Policy |
| Inflammatory Conditions - Cibinqo PA Policy-1 | Policy |
| Inflammatory Conditions - Cimzia DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Cimzia DQM Policy - Per Days-1 | Policy |
| Inflammatory Conditions - Cimzia PA Policy | Policy |
| Inflammatory Conditions - Cimzia PA Policy-1 | Policy |
| Inflammatory Conditions - Cosentyx Subcutaneous DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Cosentyx Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Entyvio Intravenous PA Policy | Policy |
| Inflammatory Conditions - Entyvio Intravenous PA Policy-1 | Policy |
| Inflammatory Conditions - Entyvio Intravenous PA Policy-2 | Policy |
| Inflammatory Conditions - Etanercept Products DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Etanercept Products PA Policy | Policy |
| Inflammatory Conditions - Etanercept Products PA Policy-1 | Policy |
| Inflammatory Conditions - Etanercept Products PA Policy-2 | Policy |
| Inflammatory Conditions - Ilaris DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Ilaris PA Policy | Policy |
| Inflammatory Conditions - Ilaris PA Policy-1 | Policy |
| Inflammatory Conditions - Ilaris PA Policy-2 | Policy |
| Inflammatory Conditions - Ilumya DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Ilumya PA Policy | Policy |
| Inflammatory Conditions - Ilumya PA Policy-1 | Policy |
| Inflammatory Conditions - Infliximab Intravenous Products PA Policy | Policy |
| Inflammatory Conditions - Infliximab Intravenous Products PA Policy-1 | Policy |
| Inflammatory Conditions - Infliximab Intravenous Products PA Policy-2 | Policy |
| Inflammatory Conditions - Infliximab Intravenous Products PA Policy-3 | Policy |
| Inflammatory Conditions - Kevzara PA Policy | Policy |
| Inflammatory Conditions - Kevzara PA Policy-1 | Policy |
| Inflammatory Conditions - Kineret DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Kineret DQM Policy - Per Days-1 | Policy |
| Inflammatory Conditions - Kineret PA Policy | Policy |
| Inflammatory Conditions - Kineret PA Policy-1 | Policy |
| Inflammatory Conditions - Kineret PA Policy-2 | Policy |
| Inflammatory Conditions - Kineret PA Policy-3 | Policy |
| Inflammatory Conditions - Kineret PA Policy-4 | Policy |
| Inflammatory Conditions - Olumiant PA Policy | Policy |
| Inflammatory Conditions - Olumiant PA Policy-1 | Policy |
| Inflammatory Conditions - Orencia Intravenous PA Policy | Policy |
| Inflammatory Conditions - Orencia Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Otezla DQM Policy - Per Days | Policy |
| Inflammatory Conditions - Otezla Otezla XR PA Policy | Policy |
| Inflammatory Conditions - Otezla Otezla XR PA Policy-1 | Policy |