Xeljanz — Medical Mutual

Initial criteria

• Patient is age ≥ 18 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 will be used in combination with methotrexate or another conventional synthetic DMARD, unless contraindicated; AND
• The medication is prescribed by or in consultation with a rheumatologist or a dermatologist.

Reauthorization criteria

• Patient has been established on therapy for at least 6 months; AND
• The medication will be used in combination with methotrexate or another conventional synthetic DMARD, unless contraindicated; 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 less joint pain, morning stiffness, or fatigue; improved function or activities of daily living; decreased soft tissue swelling in joints or tendon sheaths.

Approval duration

initial 6 months, reauth 1 year