Xeljanz — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity does not exceed program limit OR requested quantity exceeds limit AND one of the following:
• Requested dose previously approved and continuation of therapy (same dose and quantity) OR
• Adalimumab 40 mg weekly for RA or Crohn’s and failed adalimumab 40 mg every other week OR
• Xeljanz/Xeljanz XR for ulcerative colitis: both of the following: support for dose exceeding quantity limit (e.g., loss of response to labeled maintenance dose, restart of induction; medical records required) AND requested quantity cannot be achieved with lower quantity of higher strength not exceeding limit OR
• Xeljanz oral solution for pcJIA: requested dose ≤ FDA max (5 mg twice daily) and support for why patient cannot take 5 mg tablets OR
• Requested dose exceeds FDA max and patient failed ≥3 months therapy at max FDA dose (medical records required) AND one of the following: requested quantity ≤ maximum compendia supported dose and cannot be achieved with lower quantity of higher strength OR requested dose exceeds both FDA and compendia supported max and there is support for therapy with higher dose (clinical evidence required)