Xeljanz XR (tofacitinib) — Highmark

Preferred products

• adalimumab product

Initial criteria

• age ≥ 18 years
• diagnosis of moderate or severe ulcerative colitis
• prescribed by or in consultation with a gastroenterologist
• experienced therapeutic failure or intolerance to a preferred adalimumab product for the treatment of ulcerative colitis

Reauthorization criteria

• member has demonstrated disease stability or a beneficial response to therapy

Approval duration

12 months