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.

Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy	Policy
Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy	Policy
Ophthalmic Corticosteroids Step Therapy Policy	Policy
Ophthalmic Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy	Policy
Ophthalmology - Dry Eye Disease - Cyclosporine Products PA	Policy
Ophthalmology - Dry Eye Disease - Eysuvis PA Policy	Policy
Ophthalmology - Dry Eye Disease - Lacrisert DQM Policy - Per Rx	Policy
Ophthalmology - Dry Eye Disease - Lacrisert PA Policy	Policy
Ophthalmology - Dry Eye Disease - Miebo PA Policy	Policy
Ophthalmology - Dry Eye Disease - Tryptyr PA Policy	Policy
Ophthalmology - Dry Eye Disease - Tyrvaya PA Policy	Policy
Ophthalmology - Dry Eye Disease - Xiidra PA Policy	Policy
Ophthalmology - Gene Therapy - Encelto PA Policy	Policy
Ophthalmology - Gene Therapy - Luxturna PA Policy	Policy
Ophthalmology - iDose TR PA Policy	Policy
Ophthalmology - Izervay PA Policy	Policy
Ophthalmology - Oxervate PA Policy	Policy
Ophthalmology - Syfovre PA Policy	Policy
Ophthalmology - Tepezza PA Policy	Policy
Ophthalmology - Upneeq PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Aflibercept Products PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Aflibercept Products PSM Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Ranibizumab Products PSM Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA Policy	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA Policy	Policy
Ophthalmology - Verkazia PA Policy	Policy
Opioids - Butorphanol DQM Policy - Per Days	Policy
Opioids - Fentanyl Transdermal Products DQM Policy - Per Days	Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy	Policy
Opioids - Fentanyl Transmucosal Products DQM Policy - Per Days	Policy
Opioids - Long-Acting Products (Oral) DQM Policy - Per Days	Policy
Opioids - Long-Acting Products PA Policy	Policy
Opioids - Methadone PA Policy	Policy
Opioids - Nucynta DQM Policy - Per Rx	Policy
Opioids - Tramadol Extended-Release Products DQM Policy - Per Rx	Policy
Opioids - Tramadol Extended-Release Products PA Policy	Policy
Overactive Bladder Medications Step Therapy Policy	Policy
Pain - Journavx DQM Policy - Per Days	Policy
Papillomatosis - Papzimeos PA Policy	Policy
Phenylketonuria - Palynziq DQM Policy - Per Rx	Policy
Phenylketonuria - Palynziq PA Policy	Policy
Phenylketonuria - Sapropterin PA Policy	Policy
Phenylketonuria - Sephience PA Policy	Policy
Pheochromocytoma - Metyrosine and Phenoxybenzamine (Oral) PA Policy	Policy
Phosphate Binders DQM Policy - Per Rx	Policy
Pompe Disease - Enzyme Replacement Therapy - Lumizyme PA Policy	Policy
Pompe Disease - Enzyme Replacement Therapy - Nexviazyme PA Policy	Policy
Pompe Disease - Enzyme Replacement Therapy - Pombiliti PA Policy	Policy
Pompe Disease - Enzyme Stabilization Therapy - Opfolda PA Policy	Policy
Potassium Binders - Lokelma DQM Policy - Per Rx	Policy
Potassium Binders - Veltassa DQM Policy - Per Rx	Policy
Prader-Willi Syndrome - Vykat XR PA Policy	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Repatha DQM Policy - Per Days	Policy
Proton Pump Inhibitors DQM Policy - Per Rx	Policy
Proton Pump Inhibitors Step Therapy Policy	Policy
Psychiatry - Novel Psychotropics DQM Policy - Per Rx	Policy
Psychiatry - Spravato PA Policy	Policy
Psychiatry - Zurzuvae PA Policy	Policy
Pulmonary - Antifibrotics - Jascayd PA Policy	Policy
Pulmonary - Antifibrotics - Ofev PA Policy	Policy
Pulmonary - Antifibrotics - Pirfenidone PSM Policy	Policy
Pulmonary - Brinsupri PA Policy	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers DQM Policy - Per Rx	Policy
Pulmonary - Roflumilast PA with Step Therapy Policy	Policy
Pulmonary Arterial Hypertension - Adempas DQM Policy - Per Rx	Policy
Pulmonary Arterial Hypertension - Adempas PA Policy	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PSM Policy	Policy
Pulmonary Arterial Hypertension - Orenitram DQM Policy - Per Rx	Policy
Pulmonary Arterial Hypertension - Orenitram PA Policy	Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy	Policy
Pulmonary Arterial Hypertension - Sildenafil DQM Policy - Per Rx	Policy
Pulmonary Arterial Hypertension - Treprostinil Injection PSM Policy	Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy	Policy
Pulmonary Arterial Hypertension - Winrevair PA Policy	Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy	Policy
Scenesse PA Policy	Policy
Sedative Hypnotics DQM Policy - Per Days	Policy
Sedative Hypnotics Step Therapy Policy	Policy
Sickle Cell Disease - Adakveo PA Policy	Policy
Sickle Cell Disease - Hydroxyurea Products Preferred Step Therapy Policy	Policy
Sickle Cell Disease - L-glutamine PSM Policy	Policy
Sohonos PA Policy	Policy
Somatostatin Analogs - Mycapssa DQM Policy - Per Days	Policy
Somatostatin Analogs - Mycapssa PA Policy	Policy
Somatostatin Analogs – Octreotide Immediate-Release Products PSM Policy	Policy
Somatostatin Analogs and Related Medications for Acromegaly PSM Policy	Policy
Somavert PA Policy	Policy
Spinal Muscular Atrophy - Evrysdi PA Policy	Policy
Spinal Muscular Atrophy - Gene Therapy - Itvisma PA Policy	Policy
Spinal Muscular Atrophy - Gene Therapy - Zolgensma PA Policy	Policy
Spinal Muscular Atrophy - Spinraza DQM Policy - Per Days	Policy
Spinal Muscular Atrophy - Spinraza PA Policy	Policy
Synagis PA Policy	Policy
Tasimelteon Capsules PSM Policy	Policy
Testosterone (injectable) Products PA Policy	Policy
Testosterone (Oral, Topical, and Nasal) Products PA Policy	Policy
Testosterone Products (Topical) DQM Policy - Per Rx	Policy
Tetracyclines (Oral) Step Therapy Policy	Policy

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