| Policy Number | Policy Title | Effective Date Start | Retire Date |
| CP.PHAR.488 | Apomorphine (Apokyn) (PDF) | September 1, 2020 | July 1, 2025 |
| CP.PHAR.93 | Bevacizumab (Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev) (PDF) | December 1, 2011 | September 1, 2025 |
| CP.PHAR.553 | Belzutifan (Welireg) (PDF) | December 1, 2021 | September 1, 2025 |
| HIM.PA.SP60 | Biologic and Non-biologic DMARDs (PDF) | Janurary 1, 2020 | September 1, 2025 |
| HIM.PA.103 | Brand Name Override and Non-Formulary Medications (PDF) | December 1, 2014 | August 1, 2025 |
| CP.PHAR.303 | Brentuximab Vedotin (Adcetris) (PDF) | February 1, 2017 | July 1, 2025 |
| CP.PHAR.246 | Canakinumab (Ilaris) (PDF) | July 1, 2017 | September 1, 2025 |
| CP.PHAR.349 | Ceritinib (Zykadia) (PDF) | July 1, 2017 | September 1, 2025 |
| CP.PHAR.625 | Concizumab (NN7415) (PDF) | | September 1, 2025 |
| CP.PMN.214 | Continuous Glucose Monitors (PDF) | | August 1, 2025 |
| HIM.PA.168 | Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (PDF) | | September 1, 2025 |
| CP.PHAR.155 | Cysteamine oral (Cystagon, Procysbi) (PDF) | | September 1, 2025 |
| CP.PHAR.236 | Darbepoetin alfa (Aranesp) (PDF) | | September 1, 2025 |
| CP.PHAR.593 | Delandistrogene moxeparvovec-rokl (Elevidys) (PDF) | June 22, 2023 | July 15, 2025 |
| CP.PHAR.418 | Dexrazoxane (Zinecard, Totect) (PDF) | | September 1, 2025 |
| CP.PHAR.418 | Durvalumab (Imfinzi) (PDF) | | September 1, 2025 |
| CP.PHAR.343 | Edaravone (Radicava, Radivaca ORS) (PDF) | | September 1, 2025 |
| CP.PHAR.623 | Elacestrant (Orserdu) (PDF) | | September 1, 2025 |
| CP.PHAR.103 | Immune Globulins (PDF) | August 1, 2012 | September 1, 2025 |
| CP.PHAR.656 | Iptacopan (LNP023) (PDF) | December 5, 2023 | July 1, 2025 |
| CP.PHAR.596 | Lecanemab-irmb (Leqembi) (PDF) | Janurary 6, 2023 | September 1, 2025 |
| CP.PHAR.71 | Lenalidomide (Revlimid) (PDF) | July 1, 2025 | September 1, 2025 |
| CP.PHAR.406 | Lorlatinib (Lorbrena)(PDF) | March 1, 2019 | September 1, 2025 |
| CP.PHAR.238 | Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) | | September 1, 2025 |
| CP.PHAR.164 | Miglustat (Zavesca) (PDF) | | September 1, 2025 |
| CP.PMN.125 | Milnacipran (Savella) (PDF) | | September 1, 2025 |
| CP.PHAR.259 | Natalizumab (Tysabri) (PDF) | | September 1, 2025 |
| CP.PHAR.619 | Nedosiran (DCR-PHXC) (PDF) | September 29. 2023 | September 1, 2025 |
| CP.PMN.04 | Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) (PDF) | November 15, 2017 | September 1, 2025 |
| CP.PHAR.528 | Odevixibat (Bylvay) (PDF) | | September 1, 2025 |
| CP.PHAR.306 | Ofatumumab (Arzerra, Kesimpta) (PDF) | | September 1, 2025 |
| CP.PHAR.108 | Omacetaxine (Synribo) (PDF) | | September 1, 2025 |
| CP.PMN.198 | Overactive Bladder Agents (PDF) | | September 1, 2025 |
| CP.PHAR.462 | Ozanimod (Zeposia) (PDF) | | September 1, 2025 |
| CP.PHAR.512 | Pegunigalsidase Alfa (PRX-102) (PDF) | | September 1, 2025 |
| CP.PHAR.322 | Pembrolizumab (Keytruda®) (PDF) | March 1, 2017 | September 1, 2025 |
| CP.PHAR.227 | Pertuzumab (Perjeta) (PDF) | | September 1, 2025 |
| CP.PHAR.626 | Pozelimab-bbfg (Veopoz) (PDF) | | September 1, 2025 |
| CP.PMN.33 | Pregabalin (Lyrica) (PDF) | Janurary 1, 2007 | July 1, 2025 |
| HIM.PA.159 | Prucalopride (Motegrity) (PDF) | June 1, 2021 | September 1, 2025 |
| CP.PHAR.266 | Rilonacept (Arcalyst) (PDF) | | September 1, 2025 |
| CP.PHAR.260 | Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) | July 1, 2016 | September 1, 2025 |
| CP.PHAR.43 | Sapropterin Dihydrochloride (Kuvan, Javygtor) (PDF) | | September 1, 2025 |
| CP.PHAR.491 | Setmelanotide (Imcivree) (PDF) | November 25, 2020 | July 1, 2025 |
| CP.PMN.209 | Solriamfetol (Sunosi) (PDF) | | September 1, 2025 |
| CP.PHAR.69 | Sorafenib (Nexavar) (PDF) | | September 1, 2025 |
| CP.PHAR.549 | Sotorasib (Lumakras) (PDF) | September 1, 2021 | July 1, 2025 |
| CP.PHAR.631 | Sparsentan (Filspari) (PDF) | June 1, 2023 | September 1, 2025 |
| CP.PHAR.606 | Spesolimab-sbzo (Spevigo) (PDF) | March 1, 2023 | September 1, 2025 |
| CP.PHAR.73 | Sunitinib (Sutent) (PDF) | September 1, 2011 | September 1, 2025 |
| CP.PHAR.432 | Tafamidis (Vyndaqel, Vyndamax) (PDF) | September 1, 2019 | July 1, 2025 |
| CP.PHAR.77 | Temozolomide (Temodar) (PDF) | September 1, 2011 | September 1, 2025 |
| CP.PHAR.78 | Thalidomide (Thalomid) (PDF) | | September 1, 2025 |
| CP.PMN.298 | Tirzepatide (Zepbound) (PDF) | | September 1, 2025 |
| CP.PHAR.600 | Trofinetide (Daybue) (PDF) | March 10, 2023 | July 1, 2025 |
| CP.PMN.277 | Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia)(PDF) | | September 1, 2025 |
