Xeljanz oral solution — Cigna
Juvenile Idiopathic Arthritis (patient currently receiving medication)
Preferred products
- Enbrel
- adalimumab-adbm
- Cyltezo
- adalimumab-adaz
- adalimumab-ryvk
- Simlandi
Initial criteria
- Patient meets the standard Inflammatory Conditions – Xeljanz/XR Prior Authorization Policy criteria
- AND patient meets ONE of the following:
- a) Patient has tried ONE of Enbrel or an adalimumab product (Humira, Abrilada, adalimumab-adaz, adalimumab-adbm, adalimumab-fkjp, adalimumab-aaty, adalimumab-ryvk, Simlandi, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry); a trial of Cimzia, an infliximab product (Remicade or biosimilars), or Simponi Aria also counts
- b) Patient has been established on Xeljanz for at least 90 days and prescription claims history indicates ≥90-day supply within past 130 days OR verified by prescriber if claims unavailable
Approval duration
1 year