Xeljanz XR — CareFirst (Caremark)

Non-radiographic axial spondyloarthritis

Initial criteria

Screening test for tuberculosis must be performed prior to initiating therapy.
If the screening test for TB is positive, further testing must confirm absence of active disease (e.g., chest x-ray).
Do not administer if member has active TB infection.
If latent TB is present, TB treatment must be initiated before starting the requested drug.
Member cannot use the requested medication concomitantly with any other biologic drug, targeted synthetic drug, or potent immunosuppressant such as azathioprine or cyclosporine.
Dosage must comply with FDA-approved labeling, accepted compendia, or evidence-based practice guidelines.

Continued therapy may be approved if member remains responsive to treatment and continues to meet all initial criteria, including periodic evaluation for active or latent TB and no concomitant use of other biologic or targeted synthetic immunosuppressants.