Xeljanz — Cigna
Rheumatoid Arthritis
Preferred products
- Enbrel
- adalimumab-adbm
- Cyltezo
- adalimumab-adaz
- adalimumab-ryvk
- Simlandi
- Taltz
- Otezla
- Skyrizi subcutaneous (pen or syringe)
- Stelara subcutaneous
- Imuldosa subcutaneous
- Selarsdi subcutaneous
- ustekinumab-ttwe subcutaneous
- Yesintek subcutaneous
- Tremfya subcutaneous
- Omvoh subcutaneous
- Velsipity
- Zymfentra
Initial criteria
- Patient meets the standard Inflammatory Conditions – Xeljanz/XR Prior Authorization Policy criteria
- AND Patient meets ONE of the following:
- a) For Ankylosing Spondylitis: 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 or subcutaneous) also counts
- b) For Rheumatoid Arthritis: patient has tried ONE of Enbrel or an adalimumab product (list as above); a trial of Cimzia, an infliximab product (Remicade or biosimilars), or Simponi (Aria or subcutaneous) also counts
- c) For Juvenile Idiopathic Arthritis: patient has tried ONE of Enbrel or an adalimumab product (list as above); a trial of Cimzia, an infliximab product (Remicade or biosimilars), or Simponi Aria also counts
- d) For Psoriatic Arthritis: patient has tried ONE of Enbrel or an adalimumab product (list as above); a trial of Cimzia, an infliximab product (Remicade or biosimilars), or Simponi (Aria or subcutaneous) also counts
- e) For Ulcerative Colitis: patient has tried ONE adalimumab product (list as above); a trial of an infliximab product (Remicade, biosimilars, or Zymfentra) or Simponi subcutaneous also counts
- f) Patient has been established on Xeljanz/XR 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