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.
| Muscular Dystrophy - Exondys 51 PA Policy | Policy |
| Muscular Dystrophy - Gene Therapy - Elevidys PA Policy | Policy |
| Muscular Dystrophy - Viltepso PA Policy | Policy |
| Muscular Dystrophy - Vyondys 53 PA Policy | Policy |
| Nephrology - Filspari PA Policy | Policy |
| Nephrology - Tarpeyo PA Policy | Policy |
| Nephrology - Vanrafia PA Policy | Policy |
| Nephrology - Voyxact PA Policy | Policy |
| Nephrology - Xphozah PA Policy | Policy |
| Neurology - Brineura PA Policy | Policy |
| Neurology - Daybue PA Policy | Policy |
| Neurology - Edaravone Products PA Policy | Policy |
| Neurology - Gene Therapy - Kebilidi PA Policy | Policy |
| Neurology - Gene Therapy - Lenmeldy PA Policy | Policy |
| Neurology - Gene Therapy - Skysona PA Policy | Policy |
| Neurology - Imaavy PA Policy | Policy |
| Neurology - Lyrica CR PA with Step Therapy Policy | Policy |
| Neurology - Oxybate Products PA Policy | Policy |
| Neurology - Qalsody PA Policy | Policy |
| Neurology - Riluzole Products PA Policy | Policy |
| Neurology - Rystiggo PA Policy | Policy |
| Neurology - Skyclarys PA Policy | Policy |
| Neurology - Tonmya PA with Step Therapy Policy | Policy |
| Neurology - Vyvgart Hytrulo PA Policy | Policy |
| Neurology - Vyvgart Intravenous PA Policy | Policy |
| Niemann-Pick disease type C - Aqneursa PA Policy | Policy |
| Niemann-Pick Disease Type C - Miplyffa PA Policy | Policy |
| Non-Steroidal Mineralocorticoid Receptor Antagonist - Kerendia PA Policy | Policy |
| Nonsteroidal Anti-Inflammatory Drug - Tivorbex DQM Policy - Per Rx | Policy |
| Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy | Policy |
| Nuedexta PA Policy | Policy |
| Oncology - Abiraterone Acetate PSM Policy | Policy |
| Oncology - Avmapki Fakzynja PA Policy | Policy |
| Oncology - Ayvakit PA Policy | Policy |
| Oncology - Balversa PA Policy | Policy |
| Oncology - Bexarotene (Oral) PA Policy | Policy |
| Oncology - Bexarotene (Oral) PSM Policy | Policy |
| Oncology - Bexarotene (Topical) PSM Policy | Policy |
| Oncology - Bosulif DQM Policy - Per Rx | Policy |
| Oncology - Bosulif PA Policy | Policy |
| Oncology - Cabometyx DQM Policy - Per Rx | Policy |
| Oncology - Cabometyx PA Policy | Policy |
| Oncology - Capecitabine DQM Policy - Per Rx | Policy |
| Oncology - Capecitabine PSM Policy | Policy |
| Oncology - Caprelsa PA Policy | Policy |
| Oncology - Cometriq DQM Policy - Per Rx | Policy |
| Oncology - Cometriq PA Policy | Policy |
| Oncology - Copiktra DQM Policy - Per Rx | Policy |
| Oncology - Copiktra PA Policy | Policy |
| Oncology - Dasatinib Products DQM Policy - Per Rx | Policy |
| Oncology - Dasatinib Products PSM Policy | Policy |
| Oncology - Daurismo DQM Policy - Per Rx | Policy |
| Oncology - Daurismo PA Policy | Policy |
| Oncology - Everolimus DQM Policy - Per Rx | Policy |
| Oncology - Everolimus Products PSM Policy | Policy |
| Oncology - Exkivity PA Policy | Policy |
| Oncology - Fotivda PA Policy | Policy |
| Oncology - Fruzaqla PA Policy | Policy |
| Oncology - Gomekli PA Policy | Policy |
| Oncology - Iclusig PA Policy | Policy |
| Oncology - Idhifa PA Policy | Policy |
| Oncology - Imatinib DQM Policy - Per Rx | Policy |
| Oncology - Imatinib PSM Policy | Policy |
| Oncology - Imbruvica PSM Policy | Policy |
| Oncology - Inluriyo PA Policy | Policy |
| Oncology - Inlyta PA Policy | Policy |
| Oncology - Inqovi PA Policy | Policy |
| Oncology - Inrebic PA Policy | Policy |
| Oncology - Itovebi PA Policy | Policy |
| Oncology - Iwilfin PA Policy | Policy |
| Oncology - Jakafi PA Policy | Policy |
| Oncology - Koselugo PA Policy | Policy |
| Oncology - Lapatinib DQM Policy - Per Rx | Policy |
| Oncology - Lapatinib PA Policy | Policy |
| Oncology - Lenvima PA Policy | Policy |
| Oncology - Lonsurf PA Policy | Policy |
| Oncology - Mercaptopurine Products Step Therapy Policy | Policy |
| Oncology - Modeyso PA Policy | Policy |
| Oncology - Nerlynx PA Policy | Policy |
| Oncology - Nilotinib PSM Policy | Policy |
| Oncology - Nilutamide PA Policy | Policy |
| Oncology - Ogsiveo PA Policy | Policy |
| Oncology - Ojemda PA Policy | Policy |
| Oncology - Ojjaara PA Policy | Policy |
| Oncology - Onureg PA Policy | Policy |
| Oncology - Orgovyx DQM Policy - Per Rx | Policy |
| Oncology - Orgovyx PA Policy | Policy |
| Oncology - Orserdu PA Policy | Policy |
| Oncology - Pazopanib PA Policy | Policy |
| Oncology - Pazopanib PSM Policy | Policy |
| Oncology - Piqray PA Policy | Policy |
| Oncology - Qinlock DQM Policy - Per Rx | Policy |
| Oncology - Qinlock PA Policy | Policy |
| Oncology - Romvimza PA Policy | Policy |
| Oncology - Scemblix DQM Policy - Per Rx | Policy |
| Oncology - Scemblix PA Policy | Policy |
| Oncology - Sorafenib PSM Policy | Policy |
| Oncology - Stivarga PA Policy | Policy |
| Oncology - Sunitinib PSM Policy | Policy |
| Oncology - Tasigna DQM Policy - Per Rx | Policy |