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.

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
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
Weight Loss - Appetite Suppressants and Orlistat PA Policy Policy
Xiaflex PA Policy Policy
Zokinvy PA Policy Policy
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