Colorado Rocky Mountain Health Plans Xeljanz Prior Auth

Coverage Criteria by Indication

inv-01: Initial Authorization — Rheumatoid Arthritis

Covered when ALL of the following are met:

RA initial diag: (1) Diagnosis of moderately to severely active RA

RA prior TNF: (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor

RA combination restriction: (3) Patient is not receiving Xeljanz or Xeljanz XR in combination with a systemic targeted immunomodulator for the same indication (e.g., adalimumab, certolizumab, etanercept, baricitinib, abatacept, upadacitinib, golimumab) or a potent immunosuppressant (e.g., azathioprine, cyclosporine).

Authorization will be issued for 12 months.

inv-02: Initial & Reauthorization — Psoriatic Arthritis

Covered when ALL of the following are met (initial) / Covered when BOTH of the following are met (reauthorization):

PsA initial diag: (1) Diagnosis of active PsA

PsA prior TNF: (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor

PsA combo restriction: (3) Patient is not receiving Xeljanz, Xeljanz XR, or Xeljanz Oral Solution in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab; bimekizumab; certolizumab; secukinumab; etanercept; abatacept; apremilast; upadacitinib; golimumab; risankizumab; ixekizumab; guselkumab; ustekinumab) or a potent immunosuppressant (e.g., azathioprine or cyclosporine).

Authorization will be issued for 12 months; reauthorization requires documentation of positive clinical response.

inv-03: Initial & Reauthorization — Ulcerative Colitis

Covered when ALL of the following are met (initial) / Covered when BOTH of the following are met (reauthorization):

UC initial diag: (1) Diagnosis of moderately to severely active UC

UC prior TNF: (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor

UC combo restriction: (3) Patient is not receiving Xeljanz or Xeljanz XR in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab; vedolizumab; mirikizumab; upadacitinib; golimumab; risankizumab; guselkumab; ustekinumab; ozanimod) or a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months; reauthorization requires documentation of positive clinical response.

inv-04: Initial & Reauthorization — Ankylosing Spondylitis

Covered when ALL of the following are met (initial) / Covered when BOTH of the following are met (reauthorization):

AS initial diag: (1) Diagnosis of active ankylosing spondylitis

AS prior TNF: (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor

AS combo restriction: (3) Patient is not receiving Xeljanz or Xeljanz XR in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab; bimekizumab; certolizumab; secukinumab; etanercept; baricitinib; abatacept; golimumab; upadacitinib; ixekizumab) or a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months; reauthorization requires documentation of positive clinical response.

inv-05: Initial & Reauthorization — Polyarticular Juvenile Idiopathic Arthritis (JIA)

Covered when ALL of the following are met (initial) / Covered when BOTH of the following are met (reauthorization):

JIA initial diag: (1) Diagnosis of active polyarticular course juvenile idiopathic arthritis

JIA prior TNF: (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor

JIA combo restriction: (3) Patient is not receiving Xeljanz or Xeljanz Oral Solution in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab; certolizumab; etanercept; baricitinib; abatacept; upadacitinib; golimumab) or a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months; reauthorization requires documentation of positive clinical response.

inv-06: Initial Therapy — Initial authorization

Initial authorization — Covered when ALL of the following are met

Initial Authorization: (1) History of failure, contraindication, or intolerance to at least one TNF inhibitor; (2) Patient is not receiving Xeljanz or Xeljanz Oral Solution in combination with a systemic targeted immunomodulator for the same indication; (3) Patient is not receiving Xeljanz in combination with a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

inv-07: Continuation Therapy / Reauthorization

Reauthorization — Covered when ALL of the following are met

Reauthorization response: (1) Documentation of positive clinical response to Xeljanz/Xeljanz XR/Xeljanz Oral Solution therapy

Reauth combo restriction: (2) Patient is not receiving Xeljanz in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab, certolizumab, etanercept, baricitinib, abatacept, upadacitinib, golimumab)

Reauth potent immuno restriction: (3) Patient is not receiving Xeljanz in combination with a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

The policy explicitly states that the use of Xeljanz (tofacitinib) formulations in combination with biologic DMARDs, other biologic therapies used for ulcerative colitis, or potent immunosuppressants (for example, azathioprine and cyclosporine) is not recommended. Prescribers should avoid concurrent administration of these agents with tofacitinib because such combinations fall outside the recommended use described in the policy and may lead to denial of coverage.

Coverage is excluded when a patient is receiving Xeljanz or Xeljanz Oral Solution in combination with another systemic targeted immunomodulator for the same indication (examples include adalimumab, certolizumab, etanercept, baricitinib, abatacept, upadacitinib, and golimumab) or with a potent immunosuppressant (for example, azathioprine, cyclosporine, or mycophenolate mofetil). Such concomitant use is an exclusion to approval per the policy and may result in coverage denial.

Initial Authorization Requirements

inv-23: Initial therapy requirements

Initial therapy requirements — Initial authorization criteria per indication

Initial common: Diagnosis of the specific active disease AND history of failure, contraindication, or intolerance to at least one TNF inhibitor AND no concomitant systemic targeted immunomodulator for the same indication or potent immunosuppressant use.

Authorization issued for 12 months.

inv-24: Initial authorization

Initial authorization — Initial coverage criteria may require prior biologic therapy per updated label

Initial: History of failure, contraindication, or intolerance to at least one TNF inhibitor is required for certain indications (RA, PsA, pcJIA) per label updates; patient must not be on excluded concomitant therapies.

Reauthorization / Continuation Criteria

inv-25: Reauthorization

Reauthorization — Reauthorization (continuation) criteria

Reauth response: Documentation of positive clinical response to Xeljanz/Xeljanz XR/Xeljanz Oral Solution therapy is required.

Reauth combo restriction: Patient must not be receiving concomitant systemic targeted immunomodulator for the same indication or potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization issued for 12 months.

inv-26: Reauthorization

Reauthorization — Reauthorization rules

Reauthorization: Documentation of positive clinical response; no concomitant systemic targeted immunomodulator or potent immunosuppressant; reauthorization period 12 months.

Step Therapy Requirements

Requirement	Details
Must have tried and failed or have a contraindication or intolerance to at least one TNF inhibitor before initiating tofacitinib (Xeljanz, Xeljanz XR, or Xeljanz Oral Solution).
Policy requires history of failure, contraindication, or intolerance to ≥1 TNF inhibitor as part of initial authorization for covered indications (authorization issued for 12 months).

Indication(s)	Step therapy requirement (TNF inhibitor)
Rheumatoid arthritis (moderately to severely active)
Step through at least one TNF inhibitor is required prior to tofacitinib per updated label (history of failure, contraindication, or intolerance to a TNF inhibitor).
Psoriatic arthritis (active)
Step through at least one TNF inhibitor is required prior to tofacitinib per updated label (history of failure, contraindication, or intolerance to a TNF inhibitor).
Polyarticular juvenile idiopathic arthritis (active polyarticular course)
Step through at least one TNF inhibitor is required prior to tofacitinib per updated label (history of failure, contraindication, or intolerance to a TNF inhibitor).

Provider Authorization and Documentation Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Xeljanz, Xeljanz XR, and Xeljanz Oral Solution per the payer's clinical pharmacy program. Authorization will generally be issued for 12 months.

Applies to Xeljanz, Xeljanz XR, and Xeljanz Oral Solution.
Authorization duration: 12 months.

Step Therapy

Prior TNF Inhibitor Requirement

Initial therapy for the listed adult and pediatric indications requires documentation of history of failure, contraindication, or intolerance to at least one TNF inhibitor prior to approval.

Required for: rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, ankylosing spondylitis, polyarticular juvenile idiopathic arthritis.
Documentation should specify agent(s) tried and reason for failure/contraindication/intolerance.

Key Definitions and Examples

Potent immunosuppressant — examples

DefinitionPotent immunosuppressant — examples provided in this policy include azathioprine, cyclosporine, and mycophenolate mofetil.

Clinical noteUse of potent immunosuppressants with Xeljanz/Xeljanz XR/Xeljanz Oral Solution is not recommended and may lead to denial of coverage.

Examples listed in policyAzathioprine; Cyclosporine; Mycophenolate mofetil.

Systemic targeted immunomodulator — examples

DefinitionSystemic targeted immunomodulator — examples listed in this policy include adalimumab, certolizumab (Cimzia), etanercept (Enbrel), baricitinib (Olumiant), abatacept (Orencia), upadacitinib (Rinvoq), and golimumab (Simponi).

Coverage implicationPatient must not be receiving Xeljanz/Xeljanz XR/Xeljanz Oral Solution in combination with a systemic targeted immunomodulator for the same indication; concomitant use may be excluded from approval.

Clinical Background

Tofacitinib is a Janus kinase (JAK) inhibitor indicated for multiple inflammatory conditions, including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ulcerative colitis, and in pediatric populations for certain forms of polyarticular juvenile idiopathic arthritis. The policy emphasizes that use of tofacitinib is subject to prior authorization and that, for many indications, initiation generally requires prior failure, contraindication, or intolerance to at least one TNF inhibitor.

Policy Revision History

2025-12clinical updateLatest

Psoriatic arthritis criteria updated to include Xeljanz Oral Solution for patients 2 years of age and older; background and references updated.

2025-10annual review

Annual review with updated combination examples and language; no change to clinical intent of coverage criteria.

2024-10annual review

OpenPayer

Prior authorization and reauthorization criteria for Xeljanz (tofacitinib) products

Coverage Criteria by Indication

Initial Authorization Requirements

Reauthorization / Continuation Criteria

Step Therapy Requirements

Provider Authorization and Documentation Actions

Key Definitions and Examples

Clinical Background

Policy Revision History