| Policy Number | Policy Title | Effective Date Start | Retire Date |
| CP.PCH.48 | Valbenazine (Ingrezza, Ingrezza Sprinkle) (PDF) | September 1, 2022 | January 1, 2026 |
| CP.PHAR.103 | Immune Globulins (PDF) | August 1, 2012 | February 1, 2026 |
| CP.PCH.52 | Sacubitril-Valsartan (Entresto) (PDF) | September 1, 2024 | March 1, 2026 |
| CP.PHAR.578 | Abrocitinib (Cibinqo) (PDF) | June 1, 2022 | March 1, 2026 |
| CP.PHAR.704 | Lebrikizumab (Ebglyss) (PDF) | January 1, 2025 | March 1, 2026 |
| CP.PHAR.703 | Nemolizumab-ito (Nemluvio) (PDF) | December 1, 2024 | March 1, 2026 |
| CP.PHAR.577 | Tralokinumab-ldrm (Adbry) (PDF) | June 1, 2022 | March 1, 2026 |
| CP.PMN.248 | Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) | December 1, 2020 | March 1, 2026 |
| HIM.PA.15 | Brinzolamide/Brimonidine (Simbrinza) (PDF) | September 4, 2018 | March 1, 2026 |
| CP.PHAR.576 | Tezepelumab (Tezspire) (PDF) | June 1, 2022 | March 1, 2026 |
| HIM.PA.93 | Mometasone (Nasonex) (PDF) | December 1, 2014 | March 1, 2026 |
| CP.PHAR.103 | Immune Globulins (PDF) | February 1, 2025 | February 1, 2026 |
| CP.PHAR.236 | Darbepoetin alfa (Aranesp) (PDF) | | September 1, 2026 |
| CP.PHAR.237 | Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF) | | September 1, 2026 |
| CP.PMN.35 | Armodafinil (Nuvigil) (PDF) | | September 1, 2026 |
| CP.PHAR.669 | Birch Triterpenes (Filsuvez) (PDF) | | September 1, 2026 |
| CP.PHAR.316 | Cabazitaxel (Jevtana) (PDF) | | September 1, 2026 |
| CP.PHAR.573 | Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF) | | September 1, 2026 |
| CP.PHAR.60 | Capecitabine (Xeloda) (PDF) | | September 1, 2026 |
| CP.PHAR.416 | Caplacizumab-yhdp (Cablivi) (PDF) | | September 1, 2026 |
| CP.PHAR.533 | Ciltacabtagene Autoleucel (Carvykti) (PDF) | | September 1, 2026 |
| CP.PMN.193 | Hydroxyurea (Siklos, Xromi) (PDF) | | September 1, 2026 |
| CP.PHAR.238 | Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) | | September 1, 2026 |
| CP.PHAR.558 | Mitapivat (Pyrukynd) (PDF) | | September 1, 2026 |
| CP.PMN.39 | Modafinil (Provigil) (PDF) | | September 1, 2026 |
| CP.PHAR.759 | Nerandomilast(Jascayd) (PDF) | | September 1, 2026 |
| CP.PHAR.76 | Nilotinib (Tasigna, Danziten, Nilceya) (PDF) | | September 1, 2026 |
| CP.PHAR.689 | Olezarsen (Tryngolza) (PDF) | | September 1, 2026 |
| CP.PHAR.721 | Plozasiran (ARO-APOC3) (PDF) | | September 1, 2026 |
| CP.PMN.42 | Sodium Oxybate (Xyrem, Lumryz) and Calcium Magnesium Potassium Sodium Oxybate (Xywav) (PDF) | | September 1, 2026 |
| CP.PMN.209 | Solriamfetol (Sunosi) (PDF) | | September 1, 2026 |
| CP.PHAR.337 | Telotristat ethyl (Xermelo) (PDF) | | September 1, 2026 |
| CP.PHAR.78 | Thalidomide (Thalomid) (PDF) | | September 1, 2026 |
| CP.PHAR.725 | Tiopronin Delayed-Release (Thiola EC, Venxxiva) (PDF) | | September 1, 2026 |
| CP.PHAR.677 | Vadadustat (Vafseo) (PDF) | | September 1, 2026 |
| CP.PHAR.550 | Vutrisiran (Amvuttra) (PDF) | | September 1, 2026 |
| CP.PHAR.616 | Zilucoplan (Zilbrysq) (PDF) | | September 1, 2026 |
