Xeljanz — Cigna

Initial criteria

• Patient is age > 2 years
• Patient meets ONE of the following (a or b): a) Patient has had a 3-month trial of at least one tumor necrosis factor inhibitor; OR b) Patient has tried at least one tumor necrosis factor inhibitor but was unable to tolerate a 3-month trial
• Medication is prescribed by or in consultation with a rheumatologist

Reauthorization criteria

• Patient has been established on therapy for at least 6 months
• Patient meets at least one of the following (a or b): a) When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (prior to initiating Xeljanz); OR b) Compared with baseline, patient experienced an improvement in at least one symptom or disease activity measure

Approval duration

6 months initial, 1 year continuation