Xeljanz — Medica
Psoriatic Arthritis
Preferred products
- Enbrel
- adalimumab-adbm
- adalimumab-adaz
- adalimumab-ryvk
- Simlandi
- Taltz
- Otezla
- Skyrizi subcutaneous
- Imuldosa subcutaneous
- Selarsdi subcutaneous
- ustekinumab-ttwe subcutaneous
- Yesintek subcutaneous
- Tremfya subcutaneous
- Omvoh subcutaneous
- Velsipity
- Zymfentra
Reauthorization criteria
- Patient meets the standard Inflammatory Conditions – Xeljanz/XR Prior Authorization Policy criteria; AND
- Patient meets ONE of the following:
- • Ankylosing Spondylitis: has tried ONE of Enbrel or an adalimumab product (a trial of Cimzia, an infliximab product, or Simponi also counts); OR
- • Rheumatoid Arthritis: has tried ONE of Enbrel or an adalimumab product (a trial of Cimzia, an infliximab product, or Simponi also counts); OR
- • Juvenile Idiopathic Arthritis: has tried ONE of Enbrel or an adalimumab product (a trial of Cimzia, an infliximab product, or Simponi Aria also counts); OR
- • Psoriatic Arthritis: has tried ONE of Enbrel or an adalimumab product (a trial of Cimzia, an infliximab product, or Simponi also counts); OR
- • Ulcerative Colitis: has tried ONE adalimumab product (a trial of an infliximab product, or Simponi subcutaneous also counts); OR
- • Patient has been established on Xeljanz/XR for ≥90 days and prescription claims history indicates at least a 90‑day supply of Xeljanz/XR was dispensed within the past 130 days, or verification by prescriber if claims data unavailable.
Approval duration
1 year