| Fecha de vigencia | Policy Name | Reviewed Date |
| 3/18/2020 |
Padcev (enfortumab vedotin-ejfv)
| 6/21/2023 |
| 4/15/2020 |
Palforzia™ (peanut allergen powder)
| 8/16/2023 |
| 8/15/2018 |
Palynziq™ (pegvaliase-pqpz) Injection
| 6/21/2023 |
| 1/1/2016 |
Pancreatic Enzymes
| 10/18/2023 |
| 1/1/2020 |
Pancreatic Enzymes
| 10/18/2023 |
| 1/1/2022 |
Panretin® (alitretinoin)
| 4/19/2023 |
| 1/1/2019 |
Parsabiv® (etelcalcetide) intravenous solution
| 3/15/2023 |
| 1/1/2019 |
Pediatric Antipsychotic Utilization Program
| 3/15/2023 |
| 1/1/2023 |
Pediatric Cardiovascular Products
| 11/15/2023 |
| 11/30/2022 |
Pedmark ® (sodium thiosulfate injection)
| 11/15/2023 |
| 1/1/2022 |
Pegasys (peginterferon alpha-2a)
| 8/16/2023 |
| 1/1/2024 |
Pegasys (peginterferon alpha-2a)
| 6/21/2023 |
| 1/1/2014 |
Pegasys® (peginterferon alfa-2a)
| 8/16/2023 |
| 6/3/2020 |
Pemazyre™ (pemigatinib)
| 10/18/2023 |
| 4/27/2022 |
Pemetrexed Products
| 4/19/2023 |
| 1/1/2020 |
Pennsaid® (diclofenac topical solution)
| 6/21/2023 |
| 1/1/2020 |
Perjeta® (pertuzumab)
| 5/17/2023 |
| 1/1/2020 |
Pexeva® (paroxetine mesylate)
| 5/17/2023 |
| 12/28/2022 |
Pheburane® and Olpruva™ (sodium phenylbutyrate)
| 7/19/2023 |
| 9/16/2020 |
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
| 6/21/2023 |
| 1/1/2021 |
Phosphate Binding Agents
| 7/19/2023 |
| 1/1/2021 |
Phosphate Binding Agents
| 4/19/2023 |
| 8/21/2019 |
Piqray® (alpelisib)
| 4/19/2023 |
| 1/1/2021 |
Pliaglis® (lidocaine-tetracaine) cream
| 1/18/2023 |
| 6/22/2022 |
Pluvicto (lutetium Lu 177 vipivotide tetraxetan)
| 5/17/2023 |
| 1/1/2023 |
Polivy™ (polatuzumab vedotin-piiq)
| 6/21/2023 |
| 1/1/2022 |
Pomalyst® (pomalidomide)
| 9/20/2023 |
| 1/1/2023 |
Ponvory® (ponesimod) tablet
| 5/17/2023 |
| 1/1/2020 |
Portrazza™ (necitumumab)
| 5/17/2023 |
| 12/17/2015 |
Potassium Binding Agents
| 4/19/2023 |
| 10/17/2018 |
Poteligeo® (mogamulizumab-kpkc)
| 6/15/2022 |
| 4/26/2023 |
Pradaxa® (dabigatran etexilate) oral pellet
| 4/19/2023 |
| 1/1/2020 |
Praluent® (alirocumab)
| 4/19/2023 |
| 1/1/2017 |
Prandial and Intermediate Acting Insulins
| 3/15/2023 |
| 1/1/2024 |
Prandial and Intermediate Acting Insulins
| 7/19/2023 |
| 10/13/2023 |
Preferred Adalimumab Products
| 9/20/2023 |
| 10/13/2023 |
Preferred Adalimumab Products
| 9/20/2023 |
| 10/13/2023 |
Preferred Adalimumab Products
| 11/21/2023 |
| 1/1/2024 |
Preferred Continuous Glucose Monitoring Systems
| 10/18/2023 |
| 1/1/2024 |
Preferred Infliximab Products - Inflectra (infliximab-dyyb)
| 9/20/2023 |
| 1/1/2024 |
Preferred Infliximab Products - Remicade (infliximab), Inflectra (infliximab-dyyb), and infliximab
| 9/20/2023 |
| 1/1/2024 |
Preferred Infliximab Products - Remicade (infliximab), Inflectra (infliximab-dyyb), and infliximab
| 6/21/2023 |
| 2/17/2021 |
Preferred Multiple Sclerosis Products
| 8/16/2023 |
| 1/1/2022 |
Preferred Multiple Sclerosis Products
| 9/20/2023 |
| 1/1/2024 |
Preferred Multiple Sclerosis Products
| 8/16/2023 |
| 1/1/2024 |
Preferred Multiple Sclerosis Products
| 6/21/2023 |
| 1/1/2024 |
Preferred Pegfilgrastim Products - Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), and Ziextenzo (pegfilgrastim-bmez)
| 7/19/2023 |
| 1/1/2023 |
Preferred Filgrastim Products - Nivestym (filgrastim-aafi) and Zarxio (filgrastim-sndz)
| 9/20/2023 |
| 1/1/2023 |
Preferred Pegfilgrastim Products - Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), and Udenyca (pegfilgrastim-cbqv)
| 9/20/2023 |
| 1/1/2023 |
Preferred Pegfilgrastim Products - Fulphila (pegfilgrastim-jmdb) and Udenyca (pegfilgrastim- cbqv)
| 9/20/2023 |
| 1/1/2023 |
Preferred Pegfilgrastim Products - Fulphila (pegfilgrastim-jmdb), Nyvepria (pegfilgrastim-apfg), and Ziextenzo (pegfilgrastim-bmez)
| 8/17/2022 |
| 7/30/2015 |
Prestalia® (perindopril-amlodipine)
| 3/15/2023 |
| 6/17/2020 |
Pretomanid
| 4/19/2023 |
| 1/1/2020 |
Previous Treatment/Prior Therapy/Trial
| 10/18/2023 |
| 2/21/2018 |
Prevymis™ (letermovir)
| 9/20/2023 |
| 1/23/2012 |
Prialt® (ziconotide intrathecal infusion)
| 8/16/2023 |
| 1/1/2024 |
Prialt® (ziconotide intrathecal infusion)
| 6/21/2023 |
| 9/21/2016 |
Probuphine® (buprenorphine) Implant
| 10/18/2023 |
| 6/6/2013 |
Procysbi® (cysteamine)
| 11/15/2023 |
| 10/13/2006 |
Progesterone to Prevent Preterm Birth
| 3/15/2023 |
| 1/1/2023 |
Prolastin-C® (alpha-1 proteinase inhibitor)
| 9/20/2023 |
| 8/1/2014 |
Proleukin® (aldesleukin)
| 3/15/2023 |
| 1/1/2020 |
Prolia® (denosumab)
| 4/19/2023 |
| 1/1/2020 |
Prolia® (denosumab)
| 4/19/2023 |
| 1/1/2021 |
Promacta® (eltrombopag)
| 5/17/2023 |
| 1/1/2017 |
Inhibidores de la bomba de protones
| 3/30/2023 |
| 1/1/2022 |
Inhibidores de la bomba de protones
| 3/30/2023 |
| 1/1/2024 |
Inhibidores de la bomba de protones
| 8/16/2023 |
| 5/13/2010 |
Provenge® (sipuleucel-T)
| 2/16/2022 |
| 1/1/2016 |
Provigil® (modafinil)
| 3/15/2023 |
| 1/1/2017 |
Provigil® (modafinil)
| 3/15/2023 |
| 1/1/2023 |
Pyrukynd® (mitapivat)
| 9/20/2023 |