Xeljanz Oral Solution — Medical Mutual

Initial criteria

• Patient is age > 2 years; AND
• Patient has had a 3-month trial of at least one tumor necrosis factor inhibitor OR patient has tried at least one tumor necrosis factor inhibitor but was unable to tolerate a 3-month trial; AND
• The medication is prescribed by or in consultation with a rheumatologist.

Reauthorization criteria

• Patient has been established on therapy for at least 6 months; AND
• When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline OR compared with baseline, patient experienced an improvement in at least one symptom such as improvement in limitation of motion, less joint pain or tenderness, decreased duration of morning stiffness or fatigue, improved function or activities of daily living.

Approval duration

initial 6 months, reauth 1 year