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.

Metabolic Disorders - Dojolvi PA Policy Policy
Metabolic Disorders - Imcivree DQM Policy - Per Days Policy
Metabolic Disorders - Imcivree PA Policy Policy
Metabolic Disorders - Nitisinone Products PA Policy Policy
Metabolic Disorders - Nulibry PA Policy Policy
Metabolic Disorders - Phenylbutyrate Products PA Policy Policy
Metabolic Disorders - Primary Hyperoxaluria - Oxlumo PA Policy Policy
Metabolic Disorders - Primary Hyperoxaluria - Oxlumo PA Policy-1 Policy
Metabolic Disorders - Tiopronin Products PA Policy Policy
Metabolic Disorders - Xuriden 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 - Ajovy PA Policy-1 Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy-1 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 - Triptans DQM Policy - Per Days Policy
Migraine - Triptans DQM Policy - Per Days-1 Policy
Migraine - Triptans DQM Policy - Per Rx Policy
Migraine - Triptans DQM Policy - Per Rx-1 Policy
Migraine - Ubrelvy PA Policy Policy
Migraine Medication Step Therapy Policy Policy
Migraine Medication Step Therapy Policy-1 Policy
Migraine Medication Step Therapy Policy-2 Policy
Multiple Sclerosis - CD20-Directed Cytolytic Antibody Infused Products PSM Policy Policy
Multiple Sclerosis - Dalfampridine PA Policy Policy
Multiple Sclerosis - Dalfampridine PSM Policy Policy
Multiple Sclerosis - Kesimpta DQM Policy - Per Days Policy
Multiple Sclerosis - Kesimpta DQM Policy - Per Days-1 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 - Ponvory DQM Policy - Per Days-1 Policy
Multiple Sclerosis (Injectable - Beta Interferon) - Avonex PA Policy Policy
Multiple Sclerosis (Injectable - Beta Interferon) - Avonex PA Policy-1 Policy
Multiple Sclerosis (Injectable - Beta Interferon) - Betaseron PA Policy Policy
Multiple Sclerosis (Injectable - Beta Interferon) - Betaseron PA Policy-1 Policy
Multiple Sclerosis (Injectable - Beta Interferon) - Plegridy PA Policy Policy
Multiple Sclerosis (Injectable - Beta Interferon) - Plegridy PA Policy-1 Policy
Multiple Sclerosis (Injectable - Beta Interferon) - Rebif PA Policy Policy
Multiple Sclerosis (Injectable - Beta Interferon) - Rebif PA Policy-1 Policy
Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Briumvi PA Policy Policy
Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Kesimpta PA Policy Policy
Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Kesimpta PA Policy-1 Policy
Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Ocrevus PA Policy Policy
Multiple Sclerosis (Injectable - Other) - Lemtrada PA Policy Policy
Multiple Sclerosis (Injectable) - Glatiramer Products PA Policy Policy
Multiple Sclerosis (Injectable) - Glatiramer Products PA Policy-1 Policy
Multiple Sclerosis (Oral - Fumarate) - Bafiertam PA Policy Policy
Multiple Sclerosis (Oral - Fumarate) - Bafiertam PA Policy-1 Policy
Multiple Sclerosis (Oral - Fumarate) - Dimethyl Fumarate PA Policy Policy
Multiple Sclerosis (Oral - Fumarate) - Dimethyl Fumarate PA Policy-1 Policy
Multiple Sclerosis (Oral - Fumarate) - Vumerity PA Policy Policy
Multiple Sclerosis (Oral - Fumarate) - Vumerity PA Policy-1 Policy
Multiple Sclerosis (Oral - Other) - Mavenclad PA Policy Policy
Multiple Sclerosis (Oral - Other) - Mavenclad PA Policy-1 Policy
Multiple Sclerosis (Oral - Other) - Teriflunomide PA Policy Policy
Multiple Sclerosis (Oral - Other) - Teriflunomide PA Policy-1 Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Fingolimod PA Policy Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Fingolimod PA Policy-1 Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Mayzent PA Policy Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Mayzent PA Policy-1 Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Ponvory PA Policy Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Ponvory PA Policy-1 Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Tascenso ODT PA Policy Policy
Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Tascenso ODT PA Policy-1 Policy
Multiple Sclerosis and Crohn's Disease (Injectable - Other) - Natalizumab Products PA Policy Policy
Multiple Sclerosis and Crohn's Disease (Injectable - Other) - Tysabri PA Policy Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM Policy for National Preferred, High Performance, and Basic - Choice, Alternate-1 Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM Policy for National Preferred, High Performance, and Basic - Choice, Alternate Policy
Multiple Sclerosis and Ulcerative Colitis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Zeposia PA Policy Policy
Multiple Sclerosis and Ulcerative Colitis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Zeposia PA Policy-1 Policy
Multiple Sclerosis PSM Policy Policy
Multiple Sclerosis PSM Policy-1 Policy
Multiple Sclerosis PSM Policy-2 Policy
Muscular Dystrophy - Amondys 45 PA Policy Policy
Muscular Dystrophy - Deflazacort PA Policy Policy
Muscular Dystrophy - Deflazacort PA Policy-1 Policy
Muscular Dystrophy - Deflazacort PA Policy-2 Policy
Muscular Dystrophy - Deflazacort PA Policy-3 Policy
Muscular Dystrophy - Deflazacort PSM Policy Policy
Muscular Dystrophy - Deflazacort PSM Policy-1 Policy
Muscular Dystrophy - Exondys 51 PA Policy Policy
Muscular Dystrophy - Viltepso PA Policy Policy
Muscular Dystrophy - Vyondys 53 PA Policy Policy
Muscular Dystrophy - Vyondys 53 PA Policy-1 Policy
Nasal Steroids Step Therapy Policy Policy
Nephrology - Filspari PA Policy Policy
Nephrology - Filspari PA Policy-1 Policy
Nephrology - Filspari PA Policy-2 Policy
Nephrology - Tarpeyo PA Policy Policy
Neurology - Brineura PA Policy Policy
Neurology - Edaravone Products PA Policy Policy
Neurology - Edaravone Products PA Policy-1 Policy
Neurology - Gene Therapy - Skysona PA Policy Policy
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