Blue Cross Blue Shield Iowa Xeljanz Coverage

Coverage Criteria for Tofacitinib (Xeljanz)

Rheumatoid Arthritis (Initial Authorization)

Authorization may be granted when the following conditions are met

RA initial

Prior TNF failure: Inadequate response OR intolerance OR contraindication to >=1 TNF inhibitor
Prior non‑TNF biologic/targeted synthetic: Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for moderately to severely active RA (e.g., Rinvoq, Olumiant)
Authorization of 12 months may be granted

Psoriatic Arthritis (Initial Authorization)

Authorization may be granted when ALL of the following are met

PsA initial

A: Inadequate response or intolerance to one or more TNF blockers
B: Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for active PsA (e.g., Rinvoq, Otezla)

Ankylosing Spondylitis and Non‑Radiographic Axial SpA (Initial Authorization)

Authorization may be granted when the following are met

AS/nr-axSpA initial

Prior TNF failure: Inadequate response OR intolerance OR contraindication to >=1 TNF inhibitor
Prior non‑TNF biologic/targeted synthetic: Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for AS/nr-axSpA (e.g., Rinvoq)

Ulcerative Colitis (Initial Authorization and Induction)

Authorization may be granted when specified criteria are met

UC prior biologic: Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for moderately to severely active ulcerative colitis (e.g., Rinvoq)

Authorization of 12 months may be granted

UC TNF failure induction: Member has had an inadequate response, intolerance, or contraindication to at least one TNF inhibitor

Authorization of 4 months may be granted for induction when criteria met; lowest effective dose used and higher induction dose (10 mg twice daily or 22 mg once daily) limited to the shortest necessary duration

UC hospitalized severe: Member has been hospitalized for acute, severe UC (e.g., continuous bleeding, severe toxic symptoms including fever and anorexia)

Authorization of 12 months may be granted

Articular Juvenile Idiopathic Arthritis (Initial Authorization)

Authorization may be granted when ALL of the following are met

JIA initial

Prior TNF failure: Inadequate response OR intolerance to >=1 TNF inhibitor
Prior non‑TNF biologic/targeted synthetic: Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for active JIA

Immune Checkpoint Inhibitor-Related Toxicity (Initial Authorization)

Authorization may be granted when ALL of the following are met

ICI-toxicity initial

Prior infliximab/vedolizumab failure: Inadequate response OR intolerance OR contraindication to infliximab or vedolizumab

Continuation / Maintenance Authorization

Authorization may be renewed when ALL of the following are met

RA continuation: Member is using the medication for moderately to severely active rheumatoid arthritis (RA)

AND achieves or maintains positive clinical response evidenced by >=20% improvement from baseline in tender joint count, swollen joint count, pain, or disability; authorization of 12 months may be granted

PsA continuation: Member is >=2 years of age and using the medication for psoriatic arthritis (PsA)

AND achieves or maintains low disease activity or improvement in signs/symptoms with improvement in any listed domain (e.g., swollen/tender joints, dactylitis, enthesitis, axial disease, skin/nails, function, CRP); authorization of 12 months may be granted

AS/nr-axSpA continuation: Adult member using the medication for active ankylosing spondylitis (AS) or nr-axSpA

AND achieves or maintains positive clinical response evidenced by improvement in listed domains (functional status, total spinal pain, inflammation, swollen/tender joints, CRP); authorization of 12 months may be granted

Ankylosing Spondylitis (AS) and Non-Radiographic Axial Spondyloarthritis (nr-axSpA)

Authorization of 12 months may be granted when the member is using the requested medication for active disease and achieves or maintains a positive clinical response evidenced by improvement from baseline in any of the listed measures.

AS/nr-axSpA response: Improvement in any of: A. Functional status; B. Total spinal pain; C. Inflammation (e.g., morning stiffness); D. Swollen joints; E. Tender joints; F. C-reactive protein (CRP)improvement from baseline

12-month authorization may be granted if met

Ulcerative Colitis (UC)

Authorization of 12 months may be granted for members using the medication for moderately to severely active ulcerative colitis who achieve remission, or who achieve/maintain a positive clinical response evidenced by improvement from baseline in any listed measures.

UC response/remission: Either remission OR improvement in any of: A. Stool frequency; B. Rectal bleeding; C. Urgency of defecation; D. C-reactive protein (CRP); E. Fecal calprotectin (FC); F. Appearance of the mucosa on endoscopy, CTE, MRE, or intestinal ultrasound; G. Improvement on a disease activity scoring tool (e.g., UCEIS, Mayo)remission OR improvement from baseline

12-month authorization may be granted if met

Articular Juvenile Idiopathic Arthritis (JIA)

Authorization of 12 months may be granted for members 2 years and older using the medication for active JIA who achieve or maintain a positive clinical response.

Articular Juvenile Idiopathic Arthritis (JIA) response: Improvement in any of: A. Number of joints with active arthritis; B. Number of joints with limitation of movement; C. Functional abilityimprovement from baseline

12-month authorization may be granted if met

Immune Checkpoint Inhibitor-Related Toxicity

Continuation of therapy

Immune Checkpoint Inhibitor-Related Toxicity: All members (including new members) requesting authorization for continuation of therapy must meet all requirements in the coverage criteriaN/A

Continuation requires meeting applicable coverage criteria; initial authorization for ICI-related toxicity is up to 6 months

General Safety and Concomitant Therapy

General and safety-related conditions applicable to all indications

TB screening: Member must have a documented negative tuberculosis (TB) test (TST or IGRA) within 12 months if naïve to biologic or targeted synthetic drugs; positive screening requires further testing to exclude active disease (e.g., chest x-ray) and treatment of latent TB before initiationwithin 12 months

Do not administer the requested drug to members with active TB infection

Concomitant therapy exclusion: Member cannot use the requested medication concomitantly with any other biologic drug, targeted synthetic drugs, or potent immunosuppressants such as azathioprine or cyclosporineno concurrent contraindicated agents

Triggers non-coverage if violated

This policy may not apply to members covered under the Federal Employee Program (FEP). Benefit determinations for FEP members are governed by the applicable FEP contract language in effect at the time services are rendered; verify individual member benefits under that contract.

Before initiating therapy, the member must have a documented negative tuberculosis (TB) test (TST or IGRA) within 12 months if naïve to biologic or targeted synthetic drugs. If TB screening is positive, obtain further testing to exclude active disease (for example, chest x‑ray) and treat latent TB prior to starting therapy. Do not administer the requested drug to members with active TB infection.

Xeljanz, Xeljanz XR, and Xeljanz Oral Solution are not medically necessary when the member does not meet the coverage criteria specified in this policy, including required documentation, TB screening, and restrictions on concomitant use with other biologic, targeted synthetic, or potent immunosuppressant agents.

Procedures, Billing Codes, and Quantity Limits

Procedures and billing codesmixed

N/A	No specific CPT/HCPCS/ICD codes listed in this section

Quantity limits — tablets and days' supply

Xeljanz 5 mg60 tablets per 30 days

Xeljanz 10 mg60 tablets per 30 days (limited to induction for UC)

Xeljanz XR 11 mg30 tablets per 30 days

Xeljanz XR 22 mg30 tablets per 30 days (limited to induction for UC)

Xeljanz 1 mg/mL Oral Solution10 mL per day

Prior Authorization & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for all indications. Submit a prior authorization request before initiating therapy to avoid delays or denials.

Prior authorization required for Xeljanz/Xeljanz XR/Xeljanz Oral Solution (all indications).
Failure to submit required documentation may result in delay or denial of the request.

Prior Authorization

Prior Authorization — 12 Month Approval When Response Achieved

When a positive clinical response or remission is achieved, authorization may be approved for 12 months for most indications. Specific duration rules vary by diagnosis (see documentation of clinical response requirements).

12-month authorization may be granted for RA, PsA (when combined with a conventional synthetic DMARD or after prior biologic/ts), AS/nr-axSpA, JIA (age ≥2), and UC in members who achieve or maintain response or remission.
UC: some scenarios allow 4-month authorization for induction with dosing limits when criteria met.
Immune checkpoint inhibitor–related toxicity: up to 6 months when criteria met.

Definitions and Clinical Response Measures

Compendial / less-common uses

Non-radiographic axial spondyloarthritis (nr-axSpA)Listed as a compendial use for Xeljanz in the policy.

Oligoarticular juvenile idiopathic arthritis (JIA)Listed as a compendial use for Xeljanz in the policy.

Immune checkpoint inhibitor-related toxicityListed as a compendial use for Xeljanz in the policy (e.g., checkpoint inhibitor–related diarrhea or colitis).

Remission (Ulcerative Colitis) — policy definition

Definition of remission (UC)Member achieves or maintains remission for moderately to severely active ulcerative colitis — meeting this condition may support a 12-month authorization.

Alternative to remissionA positive clinical response (improvement from baseline in specified measures such as stool frequency, rectal bleeding, urgency, CRP, fecal calprotectin, mucosal appearance on imaging/endoscopy, or disease activity scores like UCEIS or Mayo) may also support authorization.

Background on Tofacitinib (Xeljanz)

Tofacitinib (Xeljanz) is an oral Janus kinase (JAK) inhibitor indicated for multiple inflammatory conditions and selected compendial uses. Covered indications in this policy align with labeled and compendial uses including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis/non‑radiographic axial spondyloarthritis, ulcerative colitis, certain juvenile idiopathic arthritis presentations, and immune checkpoint inhibitor‑related toxicity. The policy requires prior authorization with documentation of prior therapies and clinical response, mandates TB screening and exclusion of active TB before initiation, and prohibits concomitant use with other biologic or targeted synthetic agents or potent immunosuppressants.

Policy Revision History

2026-04-01next_review_date

Next scheduled policy review date (per header schema).

2026-03-13effective_dateLatest

Policy current effective date updated to March 13, 2026.

2026-01-01revised

Policy revised January 2026 (document metadata indicates a revision in January 2026).

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Xeljanz (tofacitinib) — Coverage Criteria

Coverage Criteria for Tofacitinib (Xeljanz)

Procedures, Billing Codes, and Quantity Limits

Prior Authorization & Documentation Requirements

Definitions and Clinical Response Measures

Background on Tofacitinib (Xeljanz)

Policy Revision History