To easily search for a policy, use the Ctrl+F (Command+F on Mac) function on your keyboard to search by keyword, policy number or effective date. 

What are Clinical Policies?

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include policies relating to evolving medical technologies and procedures as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice, including peer-reviewed medical literature, government agency/program approval status, evidence-based guidelines, positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas affected by the policy, and other available clinical information.

All policies found on the QualChoice Clinical Policy page apply to QualChoice members. Policies on this QualChoice page may have either a “QualChoice” or a “Centene” heading. QualChoice follows care guidelines published by InterQual.
QualChoice may, from time to time, delegate utilization management of specific services. In such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure, or treatment that is not addressed in the policies on this page or within the InterQual criteria is payable by QualChoice.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

What are Payment Policies?

Healthcare claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether healthcare services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include claims processing guidelines referenced by the Centers for Medicare & Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), CPT® guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of healthcare and medical necessity, ClaimsXten™ review, and, at times, state-specific claims reimbursement guidance. More information about ClaimsXten and the way we utilize ClaimsXten with relation to claims payments can be found on our Claims and Payment Information page.

All policies found on this page apply with respect to QualChoice members. These payment policies may have either a “QualChoice” or a “Centene” heading. QualChoice may, from time-to-time, employ a vendor that applies payment policies to specific services. In such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure, or treatment that is not addressed in these policies is payable by QualChoice.

Clinical Policies for CT/CTA/CCTA, MRI, MRA, and Pet scans can also be found at the Evolent website.

            
Policy Title Policy Number Effective Date
25-hydroxyvitamin D Testing in Children and Adolescents (PDF) CP.MP.157 November 1, 2024
Air Ambulance (PDF) CP.MP.175 July 1, 2024
Ambulance Services QCP.CP.045 May 1, 2024
Allergy Immunotherapy (PDF) QCP.CP.020 May 1, 2024
Allergy Testing & Treatment (PDF) CP.MP.100 November 1, 2024
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) CP.MP.108 October 1, 2024
Alternative or Complementary Healing (PDF) QCP.CP.018 May 1, 2024
Applied Behavioral Analysis (PDF) CP.BH.104 May 1, 2024
Articular Cartilage Defect Repairs (PDF) CP.MP.26 May 1, 2024
Assisted Reproductive Technology (PDF) CP.MP.55 May 1, 2024
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) CP.BH.124 May 1, 2024
Back Braces (PDF) QCP.CP.038 May 1, 2024
Bariatric Surgery: Federal Employees Health Benefits (PDF) QCP.CP.029 May 1, 2024
Behavioral Health Treatment Documentation Requirements (PDF) CP.BH.500 July 1, 2024
Biofeedback (PDF) CP.MP.168 May 1, 2024
Biofeedback for Behavioral Health Disorders (PDF) CP.BH.300 May 1, 2024
Bone-Anchored Hearing Aids (PDF) AR.CP.MP.93 May 1, 2024
Burn Surgery (PDF) CP.MP.186 May 1, 2024
Cardiac Biomarker Testing (PDF) CP.MP.156 November 1, 2024
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 August 1, 2024
Clinical Trials (PDF) CP.MP.94 August 1, 2024
Cochlear Implanted Replacements (PDF) AR.CP.MP.14 May 1, 2024
Concert Genetics Oncology: Algorithmic Testing (PDF) V2.2023 May 1, 2024
Concert Genetics Oncology: Cancer Screening (PDF) V2.2023 May 1, 2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating
Tumor Cells (Liquid Biopsy) (PDF)
V2.2023 May 1, 2024
Concert Genetics Oncology: Cytogenetic Testing (PDF) V2.2023 May 1, 2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Cardiac Disorders (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Dermatologic Conditions (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Eye Disorders (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: General Approach to Genetic Testing (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Hearing Loss (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF) V2.2023  May 1, 2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Kidney Disorders (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Lung Disorders (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Pharmacogenetics (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF) V2.2023 May 1, 2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF) V2.2023 May 1, 2024
Corneal Remodeling (f.n.a. Refractive Surgical Procedures) (PDF) QCP.CP.021 May 1, 2024
Corneal Topography (PDF) QCP.CP.022 May 1, 2024
Cosmetic and Reconstructive Procedures (PDF) CP.MP.31 October 1, 2024
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF) CP.BH.201 August 1, 2024
Diabetic Shoe & Shoe Inserts (PDF) QCP.CP.023 May 1, 2024
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 May 1, 2024
Digital EEG Spike Analysis (PDF) CP.MP.105 November 1, 2024
Disc Decompression Procedures (PDF) CP.MP.114 October 1, 2024
Discography (PDF) CP.MP.115 July 1, 2024
Donor Lymphocyte Infusion (PDF) CP.MP.101 June 1, 2024
Drugs of Abuse, Definitive Testing (PDF) CP.MP.50 November 1, 2024
Durable Medical Equipment and Orthotics Guidelines (PDF) AR.CP.MP.107 November 1, 2024
EED in the Evaluation of Headache (PDF) CP.MP.155 November 1, 2024
Electric Tumor Treating Fields (Optune) (PDF) CP.MP.145 May 1, 2024
Endometrial Ablation (PDF) CP.MP.106 November 1, 2024
Evoked Potential Testing (PDF) CP.MP.134 November 1, 2024
Experimental Technologies (PDF) CP.MP.36 June 1, 2024
Facet Joint Interventions (PDF) CP.MP.171 May 1, 2024
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) CP.MP.248 May 1, 2024
Fecal Incontinence Treatments (PDF) CP.MP.137 August 1, 2024
FEHB Fertility Preservation (PDF) QCP.CP.042 May 1, 2024
FEHBP Gender Reassignment Surgery (PDF) QCP.CP.037 May 1, 2024
FEHB Infertility Coverage (PDF) QCP.CP.027 May 1, 2024
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 May 1, 2024
Ferriscan R2-MRI (PDF) CP.MP.53 May 1, 2024
Functional MRI (PDF) CP.MP.43 May 1, 2024
Gastric Electrical Stimulation (PDF) CP.MP.40 May 1, 2024
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) CP.MP.209 May 1, 2024
Gender Affirming Procedures (PDF) CP.MP.95 May 1, 2024
H. Pylori Serology Testing (PDF) CP.MP.153 November 1, 2024
Habilitative Services (PDF) QCP.CP.035 May 1, 2024
Heart-Lung Transplant (PDF) CP.MP.132 May 1, 2024
Holter Monitors (PDF) CP.MP.113 May 1, 2024
Home Ventilators (PDF) CP.MP.184 October 1, 2024
Hospice Services (PDF) CP.MP.54 May 1, 2024
Hyperhidrosis Treatments (PDF) CP.MP.62 June 1, 2024
Hypnotherapy (PDF) QCP.CP.014 May 1, 2024
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 May 1, 2024
Implantable Intrathecal or Epidural Pain Pump (PDF) CP.MP.173 May 1, 2024
Implantable Loop Recorder (PDF) CP.MP.243 May 1, 2024
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 June 1, 2024
Infertility Diagnosis and Treatment (PDF) QCP.CP.015 May 1, 2024
Intensity-Modulated Radiotherapy (PDF) CP.MP.69 May 1, 2024
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 July 1, 2024
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 May 1, 2024
Intraocular Lenses (PDF) QCP.CP.009 May 1, 2024
Intraoperative Neurophysiological Monitoring (PDF) QCP.CP.033 May 1, 2024
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF) CP.MP.61 October 1, 2024
Knee Braces (PDF) QCP.CP.039 May 1, 2024
Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (PDF) CP.MP.250 May 1, 2024
Liposuction for Lipedema (PDF) CP.MP.244 July 1, 2024
Lung Transplantation (PDF) CP.MP.57 June 1, 2024
Lysis of Epidural Lesions (PDF) CP.MP.116 July 1, 2024
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) CP.MP.152 November 1, 2024
Mechanical Stretch devices for joint stiffness or contractures (PDF) CP.MP.144 May 1, 2024
Medical Services that Require Dental Services (PDF) QCP.CP.030 May 1, 2024
Midwife QCP.CP.043 May 1, 2024
Multiple Sleep Latency Testing (PDF) CP.MP.24 July 1, 2024
Neonatal Abstinence Syndrome Guidelines (PDF) CP.MP.86 May 1, 2024
Neonatal Sepsis Management (PDF) CP.MP.85 May 1, 2024
Nerve Blocks for Pain Management (PDF) CP.MP.170 June 1, 2024
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) CP.MP.48 August 1, 2024
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 May 1, 2024
NICU Discharge Guidelines (PDF) CP.MP.81 May 1, 2024
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF) CP.MP.141 May 1, 2024
Obesity Management & Bariatric Surgery (PDF) QCP.CP.041 May 1, 2024
Obstetrical Home Care Programs (PDF) CP.MP.91 July 1, 2024
Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy (PDF) CP.MP.249 August 1, 2024
Orthognathic Surgery (PDF) CP.MP.202  October 1, 2024
Osteogenic Stimulation (PDF) CP.MP.194 May 1, 2024
Pancreas Transplantation (PDF) CP.MP.102 May 1, 2024
Panniculectomy (PDF) CP.MP.109 October 1, 2024
Pediatric Heart Transplant (PDF) CP.MP.138 October 1, 2024
Pediatric Kidney Transplant (PDF) CP.MP.246 June 1, 2024
Pediatric Liver Transplant (PDF) CP.MP.120 July 1, 2024
Pediatric Oral Function Therapy (PDF) CP.MP.188 July 1, 2024
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 July 1, 2024
Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 October 1, 2024
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 August 1, 2024
PPO Infertility Treatment (PDF) QCP.CP.031 May 1, 2024
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 May 1, 2024
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 May 1, 2024
Prosthetics (PDF) QCP.CP.028 May 1, 2024
Proton and Neutron Beam Therapies (PDF) CP.MP.70 May 1, 2024
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 May 1, 2024
Repair of Nasal Valve Compromise (PDF) CP.MP.210 July 1, 2024
Sacroiliac Joint Fusion (PDF) CP.MP.126 October 1, 2024
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 May 1, 2024
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF) CP.MP.146 May 1, 2024
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) CP.MP.174 May 1, 2024
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 May 1, 2024
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF) CP.MP.185 August 1, 2024
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF) CP.MP.117 October 1, 2024
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 May 1, 2024
Substance Use Disorders Treatment and Services (PDF) CP.BH.100 May 1, 2024
Tandem Transplant (PDF) CP.MP.162 May 1, 2024
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 May 1, 2024
Therapeutic Utilization of Inhaled Nitric Oxide (PDF) CP.MP.87 July 1, 2024
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) CP.MP.154 November 1, 2024
TMJ Coverage (PDF) QCP.CP.026 May 1, 2024
Total Artificial Heart (PDF) CP.MP.127 August 1, 2024
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 May 1, 2024
Transplant Service Documentation Requirements (PDF) CP.MP.247 May 1, 2024
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF) CP.BH.200 August 1, 2024
Trigger Point Injections for Pain Management (PDF) CP.MP.169 May 1, 2024
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 May 1, 2024
Vagus Nerve Stimulation (PDF) CP.MP.12 May 1, 2024
Ventricular Assist Devices (PDF) CP.MP.46 May 1, 2024
Wireless Motility Capsule (PDF) CP.MP.143 November 1, 2024
                     
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 May 1, 2024
Add-On Code Billed Without Primary Code (PDF) CC.PP.030 May 1, 2024
Ambulatory EEG (PDF) CP.MP.96 May 1, 2024
Assistant Surgeon (PDF) CC.PP.029 May 1, 2024
Autism Spectrum Disorder Treatment QCP.CP.044 May 1, 2024
Bronchial Thermoplasty (PDF) CP.MP.110 November 1, 2023
Clean Claims (PDF) CC.PP.021 May 1, 2024
Coding Overview (PDF) CC.PP.011 May 1, 2024
Cosmetic Procedures (PDF) CC.PP.024 May 1, 2024
E&M Medical Decision-Making (PDF) CC.PP.051 May 1, 2024
Emergency Department Care QCP.PP.040 May 1, 2024
Global Maternity Billing (PDF) CC.PP.016 May 1, 2024
Hospice Services (PDF) CP.MP.54 May 1, 2024
Inpatient Consultation (PDF) CC.PP.038 May 1, 2024
Inpatient Only Procedures (PDF) MP.PP.018 May 1, 2024
Laser Therapy for Skin Conditions (PDF) CP.MP.123 November 1, 2024
Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) CP.MP.139 November 1, 2024
Maximum Units (PDF) CC.PP.007 May 1, 2024
Moderate Conscious Sedation (PDF) CC.PP.015 May 1, 2024
Modifier DOS Validation (PDF) CC.PP.034 May 1, 2024
Modifier to Procedure Code Validation (PDF) CC.PP.028 May 1, 2024
Multiple CPT Code Replacement (PDF) CC.PP.033 May 1, 2024
NCCI Unbundling (PDF) CC.PP.031 May 1, 2024
Never Paid Events (PDF) CC.PP.017 May 1, 2024
Non Face-to-Face Services (PDF) QCP.PP.017 May 1, 2024
Outpatient Consultation (PDF) CC.PP.039 May 1, 2024
Pediatric Dental (PDF) QCP.PP.036 May 1, 2024
Physician Extenders (PDF) QCP.PP.032 May 1, 2024
Place of Service Mismatch (PDF) CC.PP.063  May 1, 2024
Platelet Rich Plasma (PDF) QCP.PP.010 May 1, 2024
Post-Operative Visits (PDF) CC.PP.042 May 1, 2024
Pre-Operative Visits (PDF) CC.PP.041 May 1, 2024
Preventive Health Benefit (PDF) QCP.PP.016 May 1, 2024
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 May 1, 2024
Prolonged Medical Services (PDF) QCP.PP.013 May 1, 2024
Pulmonary Function Testing (PDF) CP.MP.242 November 1, 2024
Pulse Oximetry (PDF) CC.PP.025 May 1, 2024
Robotic Surgery (PDF) CC.PP.050 May 1, 2024
Routine & Complex Office Procedures (PDF) QCP.PP.025 May 1, 2024
Same Day Visits (PDF) CC.PP.040 May 1, 2024
Severe Malnutrition (PDF) CC.PP.145 November 1, 2024
Sex Assignment (PDF) QCP.PP.012 May 1, 2024
Skilled Nursing Facility Leveling (PDF) CC.PP.206 October 1, 2024
Status "B" Bundled Services (PDF) CC.PP.046 May 1, 2024
Status P Bundled Services (PDF) CC.PP.049 May 1, 2024
Sterilization (PDF) QCP.PP.008 May 1, 2024
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 May 1, 2024
Transgender Related Services (PDF) CC.PP.047 May 1, 2024
Ultrasound in Pregnancy (PDF) CP.MP.38 November 1, 2024
Unbundled Professional Services (PDF) CC.PP.043 May 1, 2024
Unlisted Procedure Codes (PDF) CC.PP.009 May 1, 2024
Urine Specimen Validity Testing (PDF) CC.PP.056 May 1, 2024
Urodynamic Testing (PDF) CP.MP.98 November 1, 2024
Women's Preventive Health Care - Contraception (PDF) QCP.PP.011 May 1, 2024
                                           
Policy Title Policy Number Effective Date
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 June 1, 2024
Actemra (PDF) QCP.PHAR.001 Retire by January 1, 2025
ADAMTS13, recombinant-krhn (Adzynma) (PDF) CP.PHAR.635 August 1, 2024
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 June 1, 2024
Aducanumab-avwa (Aduhelm) (PDF) CP.PHAR.468 June 1, 2024
Afamelanotide (Scenesse) (PDF) CP.PHAR.444 May 1, 2024
Aflibercept (Eylea, Eylea HD) (PDF) CP.PHAR.184 November 1, 2024
Aflibercept (Eylea, Eylea HD) (PDF)  CP.PHAR.184  Retire by November 1, 2024
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158 July 1, 2024
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 June 1, 2024
Alglucosidase Alfa (Lumizyme) (PDF) CP.PHAR.160 July 1, 2024
Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF) CP.PHAR.562 May 1, 2024
Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF) CP.PHAR.563 May 1, 2024
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) CP.PHAR.94 May 1, 2024
Amisulpride (Barhemsys) (PDF)  CP.PMN.236  October 1, 2024
Amivantamab-vmjw (Rybrevant) (PDF) CP.PHAR.544 November 1, 2024
Amivantamab-vmjw (Rybrevant) (PDF)  CP.PHAR.544  Retire by November 1, 2024
Anifrolumab-fnia (Saphnelo) (PDF) CP.PHAR.551 May 1, 2024
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 May 1, 2024
Antithrombin III (ATryn, Thrombate III) (PDF) CP.PHAR.564 May 1, 2024
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) CP.PHAR.506 May 1, 2024
Aripiprazole Long-Acting Injections (Abilify Maintena, Abilify Asimtufii, Aristada, Aristada Initio) (PDF) CP.PHAR.290 May 1, 2024
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 May 1, 2024
Atidarsagene autotemcel (Lenmeldy) (PDF) CP.PHAR.602 September 1, 2024
Avacincaptad pegol (Izervay) (PDF) CP.PHAR.641 June 1, 2024
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) CP.PHAR.521 July 1, 2024
Avelumab (Bavencio) (PDF) CP.PHAR.333 May 1, 2024
Axicabtagene Ciloleucel (Yescarta) (PDF) CP.PHAR.362 May 1, 2024
Azacitidine (Onureg, Vidaza) (PDF) CP.PHAR.387 May 1, 2024
Belantamab Mafodotin-blmf (Blenrep) (PDF) CP.PHAR.469 June 1, 2024
Belatacept (Nulojix) (PDF) CP.PHAR.201 May 1, 2024
Belimumab (Benlysta) (PDF) CP.PHAR.88 October 1, 2024
Belinostat (Beleodaq) (PDF) CP.PHAR.311 May 1, 2024
Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) (PDF) CP.PHAR.307 May 1, 2024
Benralizumab (Fasenra) (PDF)  CP.PHAR.373  July 1, 2024
Beremagene geperpavec-svdt (Vyjuvek) (PDF) CP.PHAR.592 September 1, 2024
Betibeglogene Autotemcel (Zynteglo) (PDF)  CP.PHAR.545  October 1, 2024
Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) (PDF) CP.PHAR.93 August 1, 2024
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 May 1, 2024
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 June 1, 2024
Biologic and Non-biologic DMARDs (PDF) HIM.PA.SP60 January 1, 2025
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 Retire by November 1, 2024
Blinatumomab (Blincyto) (PDF)  CP.PHAR.312  November 1, 2024
Bortezomib (Velcade) (PDF) CP.PHAR.410 May 1, 2024
Brentuximab Vedotin (Adcetris) (PDF)  CP.PHAR.303  October 1, 2024
Brexanolone (Zulresso) (PDF) CP.PHAR.417 June 1, 2024
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 May 1, 2024
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445 May 1, 2024
Buprenorphine Injection (Sublocade, Brixadi) (PDF) CP.PHAR.289 June 1, 2024
Burosumab-twza (Crysvita) (PDF) CP.PHAR.11 May 1, 2024
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) HIM.PA.170 September 1, 2024
Cabazitaxel (Jevtana) (PDF) CP.PHAR.316 June 1, 2024
Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF) CP.PHAR.573 October 1, 2024
Canakinumab (Ilaris) (PDF) CP.PHAR.246 July 1, 2024
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 June 1, 2024
Carfilzomib (Kyprolis) (PDF) CP.PHAR.309 May 1, 2024
Casimersen (Amondys 45) (PDF) CP.PHAR.470 May 1, 2024
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 May 1, 2024
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 October 1, 2024
Cetuximab (Erbitux) (PDF) CP.PHAR.317 May 1, 2024
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 September 1, 2024
Ciltacabtagene Autoleucel (Carvykti) (PDF) CP.PHAR.533 August 1, 2024
Collagenase Clostridium Histolyticum (Xiaflex) (PDF) CP.PHAR.82 September 1, 2024
Copanlisib (Aliqopa) (PDF) CP.PHAR.357 May 1, 2024
Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF) CP.PHAR.385 November 1, 2024
Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF)  CP.PHAR.385  Retire by November 1, 2024
Cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 May 1, 2024
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 May 1, 2024
Cytomegalovirus Immune Globulin (Cytogam) (PDF) CP.PHAR.277 September 1, 2024
Daprodustat (Jesduvroq) (PDF) CP.PHAR.628 August 1, 2024
Daptomycin (Cubicin, Cubicin RF, Dapzura RT) (PDF) CP.PHAR.351 September 1, 2024
Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF) CP.PHAR.310 November 1, 2024
Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF)  CP.PHAR.310  Retire by November 1, 2024
Daunorubicin/Cytarabine (Vyxeos) (PDF) CP.PHAR.352 May 1, 2024
DaxibotulinumtoxinA-lanm (Daxxify) (PDF) CP.PHAR.651 June 1, 2024
Deferoxamine (Desferal) (PDF) CP.PHAR.146 September 1, 2024
Degarelix Acetate (Firmagon) (PDF) CP.PHAR.170 May 1, 2024
Delafloxacin (Baxdela) (PDF) CP.PMN.115 September 1, 2024
Delandistrogene Moxeparvovec-rokl (Elevidys) (PDF) CP.PHAR.593 Retire by November 1, 2024
Delandistrogene Moxeparvovec-rokl (Elevidys) (PDF)  CP.PHAR.593  November 1, 2024
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 November 1, 2024
Denosumab (Prolia, Xgeva) (PDF)  CP.PHAR.58  Retire by November 1, 2024
Dexrazoxane (Totect) (PDF) CP.PHAR.418 July 1, 2024
Donanemab-azbt (Kisunla) (PDF) CP.PHAR.594 November 1, 2024
Dostarlimab-gxly (Jemperli) (PDF) CP.PHAR.540 November 1, 2024
Dostarlimab-gxly (Jemperli) (PDF)  CP.PHAR.540  Retire by November 1, 2024
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 November 1, 2024
Durvalumab (Imfinzi) (PDF)  CP.PHAR.339  Retire by November 1, 2024
Ecallantide (Kalbitor) (PDF) CP.PHAR.177 September 1, 2024
Eculizumab (Soliris), Eculizumab-aeeb (Bkemv), Eculizumab-aagh (Epysqli) (PDF)  CP.PHAR.97  October 1, 2024
Edaravone (Radicava, Radicava ORS) (PDF) CP.PHAR.343 June 1, 2024
Efgartigimod Alfa-fcab, Efgartigimod/-Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo) (PDF) CP.PHAR.555 May 1, 2024
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 June 1, 2024
Elivaldogene Autotemcel (Skysona) (PDF) CP.PHAR.556 May 1, 2024
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162 June 1, 2024
Elotuzumab (Empliciti) (PDF) CP.PHAR.308 May 1, 2024
Elranatamab-bcmm (Elrexfio) (PDF) CP.PHAR.652 June 1, 2024
Emapalumab-lzsg (Gamifant) (PDF) CP.PHAR.402 May 1, 2024
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 May 1, 2024
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41 August 1, 2024
Entyvio QCP.PHAR.002 Retire by January 1, 2025
Epcoritamab-bysp (Epkinly) (PDF) CP.PHAR.634 September 1, 2024
Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF) CP.PHAR.237 August 1, 2024
Epoprostenol (Flolan, Veletri) (PDF) CP.PHAR.192 May 1, 2024
Eptinezumab-jjmr (Vyepti) (PDF) HIM.PA.SP64 May 1, 2024
Eribulin Mesylate (Halaven) (PDF) CP.PHAR.318 May 1, 2024
Erwinia Asparaginase (Erwinaze, Rylaze) (PDF) CP.PHAR.301 May 1, 2024
Esketamine (Spravato) (PDF) CP.PMN.199 May 1, 2024
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 September 1, 2024
Eteplirsen (Exondys 51) (PDF) CP.PHAR.288 May 1, 2024
Etranacogene Dezaparvovec-drlb (Hemgenix) (PDF) CP.PHAR.580 May 1, 2024
Evinacumab-dgnb (Evkeeza) (PDF) HIM.PA.166 May 1, 2024
Exagamglogene autotemcel (Casgevy) (PDF) CP.PHAR.603 July 1, 2024
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 June 1, 2024
Factor IX Complex, Human (Profilnine) (PDF) CP.PHAR.219 June 1, 2024
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF) CP.PHAR.220 September 1, 2024
Factor VIII (Human, Recombinant) (PDF) CP.PHAR.215 June 1, 2024
Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (PDF) CP.PHAR.216 June 1, 2024
Factor XIII A-Subunit, Recombinant (Tretten) (PDF) CP.PHAR.222 May 1, 2024
Factor XIII, Human (Corifact) (PDF) CP.PHAR.221 May 1, 2024
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 August 1, 2024
Faricimab-svoa (Vabysmo) (PDF) CP.PHAR.581 October 1, 2024
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 September 1, 2024
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.480 Retire by November 1, 2024
Ferric Derisomaltose (Monoferric) (PDF)  CP.PHAR.480  November 1, 2024
Ferric Pyrophosphate (Triferic, Triferic Avnu ) (PDF) CP.PHAR.624 June 1, 2024
Ferumoxytol (Feraheme) (PDF) CP.PHAR.165 September 1, 2024
Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF) CP.PHAR.526 November 1, 2024
Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF)  CP.PHAR.526  Retire by November 1, 2024
Fidanacogene Elaparvovec-dzkt (Beqvez) (PDF) CP.PHAR.643 October 1, 2024
Filgrastim (Neupogen, Zarxio, Granix, Nivestym, Releuko, Nypozi) (PDF) CP.PHAR.297 January 1, 2025
Fosdenopterin (Nulibry) (PDF) CP.PHAR.471 June 1, 2024
Fulvestrant (Faslodex Injection) (PDF)  CP.PHAR.424  October 1, 2024
Galsulfase (Naglazyme) (PDF) CP.PHAR.161 June 1, 2024
Gemtuzumab Ozogamicin (Mylotarg) (PDF) CP.PHAR.358 May 1, 2024
Givosiran (Givlaari) (PDF) CP.PHAR.457 May 1, 2024
Glofitamab-gxbm (Columvi) (PDF) CP.PHAR.636 September 1, 2024
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 May 1, 2024
Goserelin Acetate (Zoladex) (PDF) CP.PHAR.171 May 1, 2024
Hemin (Panhematin) (PDF) CP.PHAR.181 May 1, 2024
Histrelin Acetate (Vantas, Supprelin LA) (PDF) CP.PHAR.172 July 1, 2024
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 August 1, 2024
Ibandronate Injection (Boniva) (PDF) CP.PHAR.189 May 1, 2024
Idecabtagene Vicleucel (Abecma) (PDF) CP.PHAR.481 August 1, 2024
Idursulfase (Elaprase) (PDF) CP.PHAR.156 June 1, 2024
Imetelstat (Rytelo) (PDF) CP.PHAR.690 September 1, 2024
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154 June 1, 2024
Immune Globulins (PDF) CP.PHAR.103 September 1, 2024
Inclisiran (Leqvio) (PDF) CP.PHAR.568 May 1, 2024
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 October 1, 2024
Inebilizumab-cdon (Uplizna) (PDF)  CP.PHAR.458  October 1, 2024
Infliximab QCP.PHAR.003 Retire by January 1, 2025
Inotuzumab Ozogamicin (Besponsa) (PDF) CP.PHAR.359 August 1, 2024
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) CP.PHAR.534 Retire by November 1, 2024
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)  CP.PHAR.534  November 1, 2024
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 May 1, 2024
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 May 1, 2024
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 June 1, 2024
Irinotecan Liposome (Onivyde) (PDF) CP.PHAR.304 June 1, 2024
Isatuximab-irfc (Sarclisa) (PDF) CP.PHAR.482 June 1, 2024
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 June 1, 2024
Ketamine (Ketalar) (PDF) CP.PMN.296 September 1, 2024
Lanadelumab-fylo (Takhzyro) (PDF) HIM.PA.172 May 1, 2024
Lanreotide (Somatuline Depot and Unbranded) (PDF) CP.PHAR.391 August 1, 2024
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 June 1, 2024
Lecanemab-irmb (Leqembi) (PDF) CP.PHAR.596 May 1, 2024
Lefamulin (Xenleta) (PDF) CP.PMN.219 September 1, 2024
Lenacapavir (Sunlenca) (PDF) CP.PHAR.622 May 1, 2024
Letermovir (Prevymis) (PDF) CP.PHAR.367 January 1, 2025
Letermovir (Prevymis) (PDF)  CP.PHAR.367  Retire by January 1, 2025
Leucovorin Injection (PDF) CP.PHAR.393 May 1, 2024
Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (PDF) CP.PHAR.173 May 1, 2024
Levoleucovorin (Fusilev, Khapzory) (PDF) CP.PHAR.151 May 1, 2024
Lilileucel (Amtagvi) (PDF) CP.PHAR.508 June 1, 2024
Linezolid (Zyvox) (PDF) CP.PMN.27 August 1, 2024
Lisocabtagene Maraleucel (Breyanzi) (PDF) CP.PHAR.483 August 1, 2024
Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) CP.PHAR.539 September 1, 2024
Lovotibeglogene Autotemcel (Lyfgenia) (PDF) CP.PHAR.627 August 1, 2024
Lumasiran (Oxlumo) (PDF) CP.PHAR.473 August 1, 2024
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 September 1, 2024
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 Retire by December 1, 2024
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450  December 1, 2024
Lutetium Lu 177 dotatate (Lutathera) (PDF) CP.PHAR.384 September 1, 2024
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF) CP.PHAR.582 June 1, 2024
Margetuximab-cmkb (Margenza) (PDF) CP.PHAR.522 May 1, 2024
Mecasermin (Increlex) (PDF) CP.PHAR.150 October 1, 2024
Melphalan (Hepzato) (PDF) CP.PHAR.653 May 1, 2024
Melphalan flufenamide (Pepaxto) (PDF) CP.PHAR.535 June 1, 2024
Methoxsalen (Uvadex) (PDF) HIM.PA.17 May 1, 2024
Metreleptin (Myalept) (PDF) CP.PHAR.425 September 1, 2024
Mirvetuximab soravatansine-gynx (Elahere) (PDF)  CP.PHAR.617  July 1, 2024
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) CP.PHAR.495 September 1, 2024
Mitoxantrone (PDF) CP.PHAR.258 July 1, 2024
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 May 1, 2024
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 August 1, 2024
Mosunetuzumab-axgb (Lunsumio) (PDF) CP.PHAR.618 May 1, 2024
Motixafortide (Aphexda) (PDF) CP.PHAR.655 June 1, 2024
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 May 1, 2024
Nadofaragene Firadenovec-vncg (Adstiladrin) (PDF) CP.PHAR.461 June 1, 2024
Natalizumab (Tysabri) (PDF) CP.PHAR.259 September 1, 2024
Naxitamab-gqgk (Danyelza) (PDF) CP.PHAR.523 May 1, 2024
Necitumumab (Portrazza) (PDF) CP.PHAR.320 May 1, 2024
Nedosiran (Rivfloza) (PDF) CP.PHAR.619 August 1, 2024
Nirsevimab-alip (Beyfortus) (PDF) CP.PHAR.614 September 1, 2024
Nivolumab (Opdivo) (PDF) CP.PHAR.121 August 1, 2024
Nivolumab and Relatlimab-rmbw (Opdualag) (PDF) CP.PHAR.588 September 1, 2024
Nogapendekin alfa inbakicept-pmln (Anktiva) (PDF) CP.PHAR.684 September 1, 2024
Nusinersen (Spinraza) (PDF) CP.PHAR.327 May 1, 2024
Obinutuzumab (Gazyva) (PDF) CP.PHAR.305 May 1, 2024
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 June 1, 2024
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) CP.PHAR.40 September 1, 2024
Ofatumumab (Arzerra, Kesimpta) (PDF) CP.PHAR.306 June 1, 2024
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 May 1, 2024
Olipudase Alfa-rpcp (Xenpozyme) (PDF) CP.PHAR.586 September 1, 2024
Omacetaxine (Synribo) (PDF) CP.PHAR.108 June 1, 2024
Omadacycline (Nuzyra) (PDF) CP.PMN.188 September 1, 2024
OnabotulinumtoxinA (Botox) (PDF)  CP.PHAR.232  July 1, 2024
Onasemnogene Abeparvovec (Zolgensma) (PDF) CP.PHAR.421  September 1, 2024
Orencia QCP.PHAR.004 Retire by January 1, 2025
Paclitaxel, Protein-Bound (Abraxane) (PDF) CP.PHAR.176 November 1, 2024
Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) (PDF) CP.PHAR.291 May 1, 2024
Palivizumab (Synagis) (PDF) CP.PHAR.16 May 1, 2024
Panitumumab (Vectibix) (PDF) CP.PHAR.321 May 1, 2024
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 September 1, 2024
Pasireotide (Signifor, Signifor LAR) (PDF) CP.PHAR.332 September 1, 2024
Patisiran (Onpattro) (PDF) CP.PHAR.395 July 1, 2024
Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF) CP.PHAR.353 May 1, 2024
Pegcetacoplan (Empaveli, APL-2) (PDF)  CP.PHAR.524  October 1, 2024
Pegloticase (Krystexxa) (PDF) CP.PHAR.115 May 1, 2024
Pegunigalsidase Alfa-iwxj (Elfabrio) (PDF) CP.PHAR.512 September 1, 2024
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 May 1, 2024
Pegvisomant (Somavert) (PDF) CP.PHAR.389 September 1, 2024
Pembrolizumab (Keytruda) (PDF) CP.PHAR.322 Retire by November 1, 2024
Pembrolizumab (Keytruda) (PDF)  CP.PHAR.322  November 1, 2024
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 May 1, 2024
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 June 1, 2024
Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 September 1, 2024
Plasminogen, human-tvmh (Ryplazim) (PDF) CP.PHAR.513 May 1, 2024
Plerixafor (Mozobil) (PDF)  CP.PHAR.323  October 1, 2024
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 September 1, 2024
Pozelimab-bbfg (Veopoz) (PDF) CP.PHAR.626 June 1, 2024
Pralatrexate (Folotyn) (PDF) CP.PHAR.313 May 1, 2024
Protein C Concentrate, Human (Ceprotin) (PDF) CP.PHAR.330 May 1, 2024
Ramucirumab (Cyramza) (PDF) CP.PHAR.119 May 1, 2024
Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (PDF) CP.PHAR.186 January 1, 2025
Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (PDF)  CP.PHAR.186  Retire by January 1, 2025
Ravulizumab-cwvz (Ultomiris) (PDF)  CP.PHAR.415  October 1, 2024
Reslizumab (Cinqair) (PDF) CP.PHAR.223 May 1, 2024
Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF) HIM.PA.168 May 1, 2024
Respiratory syncytial virus vaccine (Abrysvo) (PDF) CP.PHAR.658 May 1, 2024
Retifanlimab-dlwr (Zynyz) (PDF) CP.PHAR.629 July 1, 2024
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 July 1, 2024
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 June 1, 2024
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 May 1, 2024
Risperidone Long-Acting Injection (Perseris, Risperdal Consta, Rykindo, Uzedy) (PDF) CP.PHAR.293 May 1, 2024
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 August 1, 2024
Romidepsin (Istodax) (PDF) CP.PHAR.314 May 1, 2024
Romiplostim (Nplate) (PDF) CP.PHAR.179 May 1, 2024
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 January 1, 2025
Ropeginterferon Alfa-2b-njft (BESREMi) (PDF) CP.PHAR.570 July 1, 2024
Rozanolixizumab-noli (Rystiggo) (PDF) CP.PHAR.648 May 1, 2024
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 June 1, 2024
Sargramostim (Leukine) (PDF) CP.PHAR.295  October 1, 2024
Satralizumab-mwge (Enspryng) (PDF)  CP.PHAR.463  October 1, 2024
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 June 1, 2024
Secukinumab (Cosentyx) QCP.PHAR.008 Retire by January 1, 2025
Sepsis Diagnosis (PDF) CC.PP.073 November 1, 2024
Siltuximab (Sylvant) (PDF) CP.PHAR.329 May 1, 2024
Simponi Aria QCP.PHAR.005 Retire by January 1, 2025
Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (PDF) CP.PHAR.574 May 1, 2024
Skyrizi QCP.PHAR.006 Retire by January 1, 2025
Sodium thiosulfate (Pedmark) (PDF) CP.PHAR.610 June 1, 2024
Spesolimab-sbzo (Spevigo) (PDF) CP.PHAR.606 August 1, 2024
Stelara QCP.PHAR.007 Retire by January 1, 2025
Sutimlimab-jome (Enjaymo) (PDF) CP.PHAR.503 June 1, 2024
Tafasitamab-cxix (Monjuvi) (PDF) CP.PHAR.508 May 1, 2024
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 June 1, 2024
Talimogene laherepvec (Imlygic) (PDF) CP.PHAR.542 September 1, 2024
Talquetamab-tgvs (Talvey) (PDF) CP.PHAR.649 June 1, 2024
Tarlatamab-dlle (Imdelltra) (PDF) CP.PHAR.685 September 1, 2024
Tebentafusp-tebn (Kimmtrak) (PDF) CP.PHAR.575 June 1, 2024
Teclistamab-cqyv (Tecvayli) (PDF) CP.PHAR.611 May 1, 2024
Tedizolid (Sivextro) (PDF) CP.PMN.62 September 1, 2024
Temozolomide (Temodar) (PDF) CP.PHAR.77 May 1, 2024
Temsirolimus (Torisel) (PDF) CP.PHAR.324 May 1, 2024
Teplizumab-mzwv (Tzield) (PDF) CP.PHAR.492 May 1, 2024
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 May 1, 2024
Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) (PDF) CP.PHAR.354 May 1, 2024
Tezepelumab-ekko (Tezspire) (PDF) CP.PHAR.576 May 1, 2024
Thyrotropin alfa (Thyrogen) (PDF) CP.PHAR.95 September 1, 2024
Tildrakizumab (Ilumya) QCP.PHAR.009 Retire by January 1, 2025
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 May 1, 2024
Tislelizumab-jsgr (Tevimbra) (PDF) CP.PHAR.687 November 1, 2024
Tislelizumab-jsgr (Tevimbra) (PDF)  CP.PHAR.687  Retire by November 1, 2024
Tisotumab Vedotin-tftv (Tivdak) (PDF) CP.PHAR.561 August 1, 2024
Tofersen (Qalsody) (PDF) CP.PHAR.591 May 1, 2024
Topotecan (Hycamtin) (PDF) CP.PHAR.64 July 1, 2024
Toripalimab (Loqtorzi) (PDF) CP.PHAR.668 September 1, 2024
Trabectedin (Yondelis) (PDF) CP.PHAR.204 May 1, 2024
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) CP.PHAR.228 August 1, 2024
Travoprost (iDose TR) (PDF) CP.PHAR.672 August 1, 2024
Tremelimumab-actl (Imjudo) (PDF) CP.PHAR.612 Retire by December 1, 2024
Tremelimumab-actl (Imjudo) (PDF) CP.PHAR.612  December 1, 2024
Triptorelin Pamoate (Trelstar, Triptodur) (PDF) CP.PHAR.175 May 1, 2024
Ublituximab-xiiy (Briumvi) (PDF) CP.PHAR.621 June 1, 2024
Valoctocogene Roxaparvovec-rvox (Roctavian) (PDF) CP.PHAR.466 May 1, 2024
Valrubicin (Valstar) (PDF) CP.PHAR.439 May 1, 2024
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 June 1, 2024
Velmanase Alfa-tycv (Lamzede) (PDF) CP.PHAR.601 June 1, 2024
Verteporfin (Visudyne) (PDF) CP.PHAR.187 May 1, 2024
Vestronidase Alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 July 1, 2024
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 May 1, 2024
Vincristine Sulfate Liposome Injection (Marqibo) (PDF) CP.PHAR.315 August 1, 2024
Voretigene Neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 May 1, 2024
Zavegepant (Zavzpret) (PDF) CP.PHAR.630 June 1, 2024
Ziv-aflibercept (Zaltrap) (PDF) CP.PHAR.325 May 1, 2024
Zoledronic Acid (Reclast) (PDF) CP.PHAR.59 May 1, 2024