Xeljanz (tofacitinib) — Point32Health

Initial criteria

• Documented diagnosis of ulcerative colitis
• Patient age ≥ 18 years
• Prescribed by or in consultation with a gastroenterologist
• Documentation of one (1) of the following: inadequate response or adverse reaction to a corticosteroid, a 5-aminosalycylate, 6-mercaptopurine, or methotrexate OR contraindication to corticosteroids, 5-aminosalycylates, 6-mercaptopurine, and methotrexate OR the patient is moderate to high risk as evidenced by deep ulcers on colonoscopy, long segments of small and/or large bowel involvement, perianal disease, extra-intestinal manifestations (e.g., fever, weight loss, abdominal pain, intermittent nausea/vomiting), history of bowel resections, or recent hospitalization for the disease 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