| Policy Title | Policy Number | Status | Effective Date | Retire Date |
|---|---|---|---|---|
| Acupuncture | CP.MP.92 | Retired | May 1, 2024 | August 1, 2025 |
| Alternative or Complementary Healing (PDF) | QCP.CP.018 | Retired | May 1, 2024 | November 1, 2025 |
| Ambulance Services (PDF) | QCP.CP.045 | Retired | May 1, 2024 | November 1, 2025 |
| Ferriscan R2-MRI - RETIRE | CP.MP.53 | Retired | October 1, 2024 | |
| Home Ventilators | CP.MP.184 | Retired | May 1, 2024 | August 1, 2025 |
| SNF Leveling | CP.MP.206 | Retired, changed to cc.pp.206 | May 1, 2024 |
December 1, 2024 |
| Transcatheter Closure of Patent Foramen Ovale | CP.MP.151 | Retired | May 1, 2024 | December 1, 2024 |
| Alternative or Complementary Healing | QCP.CP.018 | Retired | May 1, 2024 | November 1, 2025 |
| Ambulance Services | QCP.CP.045 | Retired | May 1, 2024 | November 1, 2025 |
| Autism Spectrum Disorder Treatment | QCP.CP.044 | Retired | May 1, 2024 | November 1, 2025 |
| Corneal Topography | QCP.CP.022 | Retired | May 1, 2024 | November 1, 2025 |
| Habilitative Services | QCP.CP.035 | Retired | May 1, 2024 | November 1, 2025 |
| Obesity Management & Bariatric Surgery | QCP.CP.041 | Retired | May 1, 2024 | November 1, 2025 |
| TMJ Coverage | QCP.CP.026 | Retired | May 1, 2024 | November 1, 2025 |
| Hypnotherapy | QCP.CP.014 | Retired | May 1, 2024 | November 1, 2025 |
| Policy Title | Policy Number | Status | Retire Date |
|---|---|---|---|
| Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) | HIM.PA.SP61 | Retired | October 1, 2025 |
| Valbenazine (Ingrezza) (PDF) | CP.PCH.48 | Retiring | January 1, 2026 |
| Respiratory syncytial virus vaccine (Abrysvo) (PDF) | CP.PHAR.658 | Retiring | January 1, 2026 |
| Immune Globulins (PDF) | CP.PHAR.103 | Retiring | February 1, 2026 |
| Sacubitril/Valsartan (Entresto) (PDF) | CP.PCH.52 | Retiring | March 1, 2026 |
| Abrocitinib (Cibinqo) (PDF) | CP.PHAR.578 | Retiring | March 1, 2026 |
| Lebrikizumab (Ebglyss) (PDF) | CP.PHAR.704 | Retiring | March 1, 2026 |
| Nemolizumab-ito (Nemluvio) (PDF) | CP.PHAR.703 | Retiring | March 1, 2026 |
| Tralokinumab-ldrm (Adbry) (PDF) | CP.PHAR.577 | Retiring | March 1, 2026 |
| Copanlisib (Aliqopa) (PDF) | CP.PHAR.357 | Retiring | March 1, 2026 |
| Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) | CP.PHAR.398 | Retiring | March 1, 2026 |
| Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) | CP.PMN.248 | Retiring | March 1, 2026 |
| Brinzolamide/Brimonidine (Simbrinza) (PDF) | HIM.PA.15 | Retiring | March 1, 2026 |
| Tezepelumab-ekko (Tezspire) (PDF) | CP.PHAR.576 | Retiring | March 1, 2026 |
| Mometasone (Nasonex) (PDF) | HIM.PA.93 | Retiring | March 1, 2026 |