Xeljanz oral solution — Highmark
Polyarticular Juvenile Idiopathic Arthritis
Preferred products
- adalimumab product
- Enbrel
Initial criteria
- age ≥ 2 years
- diagnosis of polyarticular juvenile idiopathic arthritis
- prescribed by or in consultation with a rheumatologist
- member meets one of the following: experienced therapeutic failure or intolerance to at least one non-biologic DMARD, or all non-biologic DMARDs are contraindicated; OR requires initial biologic therapy due to high-risk joints, high disease activity, or high risk of disabling joint damage
- experienced therapeutic failure or intolerance to a preferred adalimumab product or Enbrel for the treatment of PJIA
Reauthorization criteria
- member has demonstrated disease stability or a beneficial response to therapy
Approval duration
12 months