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Xeljanz — United Healthcare

Polyarticular Course Juvenile Idiopathic Arthritis (pcJIA)

Initial criteria

  • Diagnosis of active polyarticular course juvenile idiopathic arthritis
  • AND one of the following: (a) History of failure, contraindication, or intolerance to at least one TNF inhibitor OR (b) Patient has a documented needle-phobia to the degree that the patient has previously refused any injectable therapy or medical procedure (refer to DSM-V-TR 300.29 for specific phobia diagnostic criteria) OR (c) Both of the following: (i) Patient is currently on Xeljanz or Xeljanz XR therapy as documented by claims history or submission of medical records (document drug, date, and duration of therapy) AND (ii) Patient has not received a manufacturer supplied sample at no cost in the prescriber’s office, or any form of assistance from the Pfizer sponsored XELSOURCE program (e.g., sample card redeemed at a pharmacy for free supply) as a means to establish current user status
  • AND Patient is not receiving Xeljanz or Xeljanz Oral Solution in combination with either of the following: (a) Targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Olumiant (baricitinib), Rinvoq (upadacitinib)] (b) Potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)
  • AND Prescribed by or in consultation with a rheumatologist
  • Patients requesting initial authorization who were established on therapy via manufacturer sample or XELSOURCE assistance must meet initial criteria as if new to therapy

Reauthorization criteria

  • Documentation of positive clinical response to Xeljanz or Xeljanz Oral Solution therapy
  • AND Patient is not receiving Xeljanz or Xeljanz Oral Solution in combination with either of the following: (a) Targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Olumiant (baricitinib), Rinvoq (upadacitinib)] (b) Potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)

Approval duration

12 months