| Effective Date | Policy Name | Reviewed Date |
| 3/18/2020 |
Padcev (enfortumab vedotin-ejfv)
| 8/19/2026 |
| 7/1/2026 |
Padcev (enfortumab vedotin-ejfv)
| 4/15/2026 |
| 7/1/2026 |
Padcev (enfortumab vedotin-ejfv)
| 4/15/2026 |
| 4/15/2020 |
Palforzia® (peanut allergen powder)
| 5/20/2026 |
| 1/1/2026 |
Palonosetron IV (Aloxi generics)
| 6/17/2026 |
| 11/26/2025 |
Palonosetron IV (Aloxi generics)
| 6/17/2026 |
| 1/28/2026 |
Palsonify™ (paltusotine)
| 1/21/2026 |
| 8/15/2018 |
Palynziq™ (pegvaliase-pqpz) Injection
| 7/15/2026 |
| 1/1/2016 |
Pancreatic Enzymes
| 7/15/2026 |
| 1/1/2025 |
Panhematin® (heme for injection) intravenous solution
| 8/19/2026 |
| 8/27/2025 |
Panhematin® (heme for injection) intravenous solution
| 8/19/2026 |
| 1/1/2022 |
Panretin® (alitretinoin)
| 12/10/2025 |
| 10/22/2025 |
Papzimeos™ (zopapogene imadenovec-drba)
| 7/15/2026 |
| 12/1/2025 |
Papzimeos™ (zopapogene imadenovec-drba)
| 7/15/2026 |
| 12/1/2025 |
Papzimeos™ (zopapogene imadenovec-drba)
| 7/15/2026 |
| 7/1/2025 |
Parsabiv® (etelcalcetide) intravenous solution
| 1/21/2026 |
| 3/1/2026 |
Parsabiv® (etelcalcetide) intravenous solution
| 1/21/2026 |
| 1/1/2019 |
Pediatric Antipsychotic Utilization Program
| 4/9/2026 |
| 10/1/2025 |
Pediatric Antipsychotic Utilization Program
| 8/28/2025 |
| 12/9/2020 |
Pediatric Adrenocortical Insufficiency Products
| 8/19/2026 |
| 11/30/2022 |
Pedmark® (sodium thiosulfate injection)
| 3/18/2026 |
| 8/27/2025 |
Pedmark® (sodium thiosulfate injection)
| 3/18/2026 |
| 1/1/2026 |
Pedmark® (sodium thiosulfate injection)
| 3/18/2026 |
| 1/1/2026 |
Pegasys (peginterferon alfa2-a)
| 6/17/2026 |
| 6/3/2020 |
Pemazyre (pemigatinib)
| 3/18/2026 |
| 1/1/2025 |
Pembrolizumab products (Keytruda, Keytruda Qlex)
| 8/19/2026 |
| 7/1/2026 |
Pembrolizumab products (Keytruda, Keytruda Qlex)
| 4/15/2026 |
| 7/1/2026 |
Pembrolizumab products (Keytruda, Keytruda Qlex)
| 4/15/2026 |
| 4/27/2022 |
Pemetrexed Products
| 9/17/2025 |
| 11/1/2025 |
Pemetrexed Products
| 9/17/2025 |
| 11/1/2025 |
Pemetrexed Products
| 9/17/2025 |
| 11/1/2025 |
Pemetrexed Products
| 9/17/2025 |
| 1/1/2026 |
Pennsaid (diclofenac topical solution)
| 7/15/2026 |
| 1/1/2020 |
Perjeta (pertuzumab)
| 1/21/2026 |
| 3/1/2026 |
Perjeta (pertuzumab)
| 1/21/2026 |
| 3/1/2026 |
Perjeta (pertuzumab)
| 1/21/2026 |
| 12/28/2022 |
Pheburane® and Olpruva™ (sodium phenylbutyrate)
| 2/18/2026 |
| 9/16/2020 |
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
| 12/10/2025 |
| 2/1/2026 |
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
| 12/10/2025 |
| 2/1/2026 |
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
| 12/10/2025 |
| 1/1/2025 |
PiaSky® (crovalimab-akkz) injection
| 7/15/2026 |
| 1/1/2025 |
Piqray (alpelisib)
| 9/17/2025 |
| 8/1/2025 |
Pluvicto (lutetium Lu 177 vipivotide tetraxetan)
| 5/20/2026 |
| 8/1/2026 |
Pluvicto (lutetium Lu 177 vipivotide tetraxetan)
| 5/20/2026 |
| 8/1/2026 |
Pluvicto (lutetium Lu 177 vipivotide tetraxetan)
| 5/20/2026 |
| 6/22/2022 |
Pluvicto (lutetium Lu 177 vipivotide tetraxetan)
| 5/20/2026 |
| 1/1/2026 |
Polivy™ (polatuzumab vedotin-piiq)
| 3/18/2026 |
| 6/1/2026 |
Polivy™ (polatuzumab vedotin-piiq)
| 3/18/2026 |
| 6/1/2026 |
Polivy™ (polatuzumab vedotin-piiq)
| 3/18/2026 |
| 1/1/2022 |
Pomalyst (pomalidomide)
| 4/30/2026 |
| 3/27/2024 |
Pombiliti® (cipaglucosidase alfa-atga)
| 12/10/2025 |
| 1/1/2020 |
Portrazza (necitumumab)
| 11/19/2025 |
| 10/17/2018 |
Poteligeo® (mogamulizumab-kpkc)
| 1/21/2026 |
| 3/1/2026 |
Poteligeo® (mogamulizumab-kpkc)
| 1/21/2026 |
| 3/1/2026 |
Poteligeo® (mogamulizumab-kpkc)
| 1/21/2026 |
| 4/26/2023 |
Pradaxa® (dabigatran etexilate) oral pellet
| 10/15/2025 |
| 1/1/2026 |
Praluent® (alirocumab)
| 1/21/2026 |
| 1/1/2026 |
Prandial and Intermediate Acting Insulins
| 5/20/2026 |
| 1/1/2026 |
Preferred Adalimumab Products
| 6/17/2026 |
| 1/1/2024 |
Preferred Continuous Glucose Monitoring Systems
| 8/19/2026 |
| 1/1/2026 |
Preferred Filgrastim Products
| 1/21/2026 |
| 1/1/2026 |
Preferred Filgrastim Products (MA/MAPD): Zarxio, Nivestym
| 1/21/2026 |
| 1/1/2026 |
Preferred Filgrastim Products (PDP): Nivestym
| 1/21/2026 |
| 1/1/2025 |
Preferred GLP-1 Agonists and GLP-1/GIP Agonists
| 6/17/2026 |
| 1/1/2024 |
Preferred Infliximab Products - Inflectra (infliximab-dyyb)
| 6/17/2026 |
| 7/1/2024 |
Preferred Infliximab Products - Inflectra (infliximab-dyyb)
| 6/17/2026 |
| 1/1/2024 |
Preferred Infliximab Products - Remicade (infliximab), Inflectra (infliximab-dyyb), and infliximab
| 5/20/2026 |
| 1/1/2026 |
Preferred Multiple Sclerosis Products
| 4/15/2026 |
| 1/1/2026 |
Preferred Pegfilgrastim Products: Neulasta/Neulasta Onpro
| 2/18/2026 |
| 1/1/2026 |
Preferred Pegfilgrastim Products: Neulasta/Neulasta Onpro, Fulphila
| 2/18/2026 |
| 1/1/2026 |
Preferred Pegfilgrastim Products: Neulasta/Neulasta Onpro, Udenyca/Udenyca Onbody, Fulphila
| 2/18/2026 |
| 1/1/2025 |
Preferred Testosterone Products
| 4/15/2026 |
| 7/1/2025 |
Preferred Ustekinumab Products
| 5/20/2026 |
| 1/1/2020 |
Previous Treatment/Prior Therapy/Trial
| 10/15/2025 |
| 2/21/2018 |
Prevymis™ (letermovir)
| 7/15/2026 |
| 1/1/2026 |
Prevymis™ (letermovir)
| 3/18/2026 |
| 1/1/2026 |
Prevymis™ (letermovir)
| 3/18/2026 |
| 1/1/2024 |
Prialt® (ziconotide intrathecal infusion)
| 11/19/2025 |
| 6/6/2013 |
Procysbi® (cysteamine)
| 3/18/2026 |
| 7/1/2026 |
Prolia® (denosumab) biosimilars
| 6/17/2026 |
| 1/1/2026 |
Promacta® (eltrombopag)
| 4/15/2026 |
| 5/13/2010 |
Provenge® (sipuleucel-T)
| 12/10/2025 |
| 2/1/2026 |
Provenge® (sipuleucel-T)
| 12/10/2025 |
| 2/1/2026 |
Provenge® (sipuleucel-T)
| 12/10/2025 |
| 1/1/2017 |
Provigil® (modafinil)
| 11/19/2025 |
| 1/1/2023 |
Pyrukynd® (mitapivat)
| 7/15/2026 |