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Xeljanz tablets — Medica

Crohn’s disease

Preferred products

  • adalimumab-adbm
  • adalimumab-adaz
  • Simlandi/adalimumab-ryvk
  • Cosentyx SC
  • Otezla
  • Skyrizi SC
  • Sotyktu
  • ustekinumab SC products (Imuldosa SC, Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC)
  • Taltz
  • Tremfya SC
  • Omvoh SC
  • Zymfentra
  • Velsipity

Initial criteria

  • Patient meets respective standard Prior Authorization Policy criteria for the requested indication.
  • Trial of Preferred Product(s) for the condition according to the table below is required prior to approval of the requested Non-Preferred Product when clinically appropriate.
  • Dermatology – Step 1: Trial of Preferred Products includes adalimumab products (adalimumab-adbm, adalimumab-adaz, Simlandi/adalimumab-ryvk), Cosentyx SC, Otezla, Skyrizi SC, Sotyktu, ustekinumab SC products (Imuldosa SC, Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC), Taltz, Tremfya SC.
  • Gastroenterology – Step 1: Trial of Preferred Products includes adalimumab products (adalimumab-adbm, adalimumab-adaz, Simlandi/adalimumab-ryvk), Omvoh SC, Skyrizi SC (on-body injector), ustekinumab SC products (Imuldosa SC, Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC), Tremfya SC, Zymfentra, Velsipity.
  • Step 2a: If inadequate response or not appropriate, trial of Step 2a Non-Preferred Products (Cimzia or Rinvoq for Crohn’s or UC directed to adalimumab specifically; Xeljanz tablets/Xeljanz XR tablets directed to adalimumab).
  • Step 2b: If inadequate response or not appropriate, trial of Step 2b Non-Preferred Product (Bimzelx) directed to one Step 1 product for dermatology indications.
  • Step 3a: If inadequate response or not appropriate, approval may be given for Step 3a Non-Preferred Products (Cimzia, Cosentyx SC, Ilumya, Siliq, Entyvio SC) when documentation supports trials of two Step 1 or 2a products.
  • Step 3b: For ulcerative colitis, Zeposia requires trial of two Step 1 products and reference to the Multiple Sclerosis and Ulcerative Colitis – Zeposia PSM Policy.
  • Documentation required for trials of Preferred Products (chart notes, prescription claims, or receipts).

Reauthorization criteria

  • Continuation of therapy requires verification of prior use via claims history or prescriber attestation consistent with continuation criteria outlined in policy.
  • Approval subject to standard PA criteria and documentation of ongoing benefit.

Approval duration

1 year