UnitedHealthcare
Xeljanz (tofacitinib)
Drugs for Pain and Fever : Arthritis and Pain Drugs
  • Quantity Limit: limit maximum 2 EA PER 1 day(s)
  • Step Therapy: Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
    ST Generic and Brand

    Juvenile Idiopathic Arthritis:
    ST Single Brand

  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Ankylosing Spondylitis (AS), Juvenile Idiopathic Arthritis, Rheumatoid Arthritis (RA):
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Psoriatic Arthritis (PsA):
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Dermatologist;Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Ulcerative Colitis (UC):
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Gastroenterologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

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