12 CONDITION EXCLUDED DRUG NAME(S) PREFERRED OPTION(S) SOTYKTU STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS YESINTEK SUBCUTANEOUS PSORIATIC ARTHRITIS AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS SIMPONI TALTZ XELJANZ XELJANZ XR ADALIMUMAB-ADAZ ADALIMUMAB-FKJP COSENTYX SUBCUTANEOUS ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) OTEZLA PYZCHIVA SUBCUTANEOUS RINVOQ SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS YESINTEK SUBCUTANEOUS RHEUMATOID ARTHRITIS ACTEMRA ACTPEN ACTEMRA SUBCUTANEOUS AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) KINERET OLUMIANT SIMPONI ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) KEVZARA ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS RINVOQ XELJANZ XELJANZ XR ULCERATIVE COLITIS AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) SIMPONI ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENTYVIO SUBCUTANEOUS HYRIMOZ (except NDCs 61314-XXXX-XX) PYZCHIVA SUBCUTANEOUS RINVOQ SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS VELSIPITY YESINTEK SUBCUTANEOUS ZEPOSIA