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.

Thrombocytopenia - Doptelet PA Policy Policy
Thrombocytopenia - Eltrombopag Products PSM Policy
Thrombocytopenia - Mulpleta PA Policy Policy
Thrombocytopenia - Nplate PA Policy Policy
Thrombocytopenia - Tavalisse PA Policy Policy
Thrombocytopenia - Wayrilz PA Policy Policy
Tolvaptan Products - tolvaptan (Jynarque) PSM Policy Policy
Tolvaptan Products DQM Policy - Per Rx Policy
Topical Acne - Cleansers Step Therapy Policy Policy
Topical Acne - Kits Step Therapy Policy Policy
Topical Acne - Winlevi PA Policy Policy
Topical Acne Products Step Therapy Policy Policy
Topical Acyclovir Products PA with Step Therapy Policy Policy
Topical Agents for Atopic Dermatitis DQM Policy - Per Days Policy
Topical Agents for Atopic Dermatitis Step Therapy Policy Policy
Topical Alpha-Adrenergic Agonists for Rosacea - Brimonidine PA Policy Policy
Topical Alpha-Adrenergic Agonists for Rosacea - Rhofade PA Policy Policy
Topical Anesthetic - Lidocaine,Tetracaine Products PA with Step Therapy Policy Policy
Topical Anesthetics DQM Policy - Per Days Policy
Topical Antibacterials Step Therapy Policy Policy
Topical Antibiotics for Acne - Clindamycin DQM Policy - Per Days Policy
Topical Antifungals DQM Policy – Per Days Policy
Topical Antifungals for Onychomycosis Step Therapy Policy Policy
Topical Antifungals for Seborrheic Dermatitis Step Therapy Policy
Topical Antipruritics - Doxepin Products DQM Policy - Per Days Policy
Topical Calcipotriene Products DQM Policy - Per Days Policy
Topical Collagenase - Santyl DQM Policy - Per Rx Policy
Topical Corticosteroids - Clobetasol DQM Policy - Per Days Policy
Topical Corticosteroids - Diflorasone DQM Policy - Per Days Policy
Topical Corticosteroids - Fluocinonide DQM Policy - Per Days Policy
Topical Corticosteroids - Flurandrenolide DQM Policy - Per Days Policy
Topical Corticosteroids - Hydrocortisone Butyrate DQM Policy - Per Days Policy
Topical Corticosteroids - Triamcinolone Topical Spray DQM Policy - Per Days Policy
Topical Corticosteroids Step Therapy Policy Policy
Topical Diclofenac Sodium 3 percent Gel PA Policy Policy
Topical Doxepin Step Therapy Policy Policy
Topical Medications for Inflammatory Rosacea Step Therapy Policy
Topical Nonsteroidal Anti-Inflammatory Drugs - Diclofenac DQM Policy - Per Days Policy
Topical Podofilox Products Step Therapy Policy Policy
Topical Products - Vtama and Zoryve 0.3% Cream Step Therapy Policy Policy
Topical Products - Zoryve Foam Step Therapy Policy Policy
Topical Retinoids - Aklief PA Policy Policy
Topical Retinoids - Panretin PA Policy Policy
Topical Retinoids - Tazarotene Products PA Policy Policy
Topical Vitamin D Analogs Step Therapy Policy Policy
Transplantation - Grafapex PA Policy Policy
Transplantation - Yartemlea PA Policy Policy
Uplizna PA Policy Policy
Vecamyl PA Policy Policy
Veregen PA Policy Policy
Vesicular Monoamine Transporter Type 2 Inhibitors DQM Policy - Per Rx Policy
Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy Policy
Vijoice PA Policy Policy
Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy Policy
Vitamin D Analog (Oral) Step Therapy Policy Policy
Wakefulness-Promoting Agents - Armodafinil, Modafinil PA with Step Therapy Policy Policy
Wakefulness-Promoting Agents - Sunosi DQM Policy - Per Rx Policy
Wakefulness-Promoting Agents - Sunosi PA with Step Therapy Policy Policy
Wakefulness-Promoting Agents - Wakix DQM Policy - Per Rx Policy
Wakefulness-Promoting Agents - Wakix PA with Step Therapy Policy Policy
Xiaflex PA Policy Policy
Zokinvy PA Policy Policy
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