Xeljanz (tofacitinib) — Point32Health

Initial criteria

• Documented diagnosis of polyarticular juvenile idiopathic arthritis
• Patient age ≥ 2 years
• Prescribed by or in consultation with a rheumatologist
• Documentation of one (1) of the following: inadequate response or adverse reaction to one disease modifying antirheumatic drug (e.g., methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) OR contraindication to all traditional disease modifying antirheumatic drugs OR previous treatment with a biologic agent indicated for the requested use OR the patient is new to the plan and has been stable on the requested agent prior to enrollment