Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 04/01/2013 Title: Xeljanz (Tofacitinib)
Revision Date: 12/01/2020 Document: BI401:00
CPT Code(s): None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Xeljanz/Xeljanz XR is used to treat rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis when other treatments have failed.

2)    Xeljanz/Xeljanz XR must be obtained through the contracted specialty pharmacy.

3)    Xeljanz/Xeljanz XR  (Tofacitinib) requires prior authorization.


Medical Statement

Xeljanz/Xeljanz XR (Tofacitinib) is considered medically necessary for adult members over 18 years of age who meet the following conditions:

Rheumatoid Arthritis

1)    Diagnosis of moderately-to-severely active rheumatoid arthritis (M05.09, M05.19, M05.29, M05.39, M05.49, M05.59, M05.69, M05.79, M05.89, M06.09, M06.89)

a.    At least 6 swollen and tender joints

b.    At least 45 minutes of morning stiffness

c.    Elevated ESR or CRP unless patient on corticosteroids

AND

2)    Experienced a an inadequate response to at least one (1) non-biologic DMARD or has contraindication to a DMARD.

 

Psoriatic Arthritis

1)    Diagnosis of psoriatic arthritis AND

2)    Greater than 3 swollen and tender joints AND

3)    Had inadequate response to at least one (1) non-biologic DMARD or has contraindication to DMARDs AND

4)    Had inadequate response to at least two (2) of preferred biologics: Humira, Simponi, Tremfya, Stelara, and Cimzia.

 

Ulcerative Colitis

1)    Diagnosis of Ulcerative Colitis And

2)    Inadequate response to BOTH at least two of the preferred biologics: Humira Stelara, and Simponi.

 

Polyarticular Juvenile Idiopathic Arthritis (PJIA) – Xeljanz only

1)    Diagnosis of polyarticular juvenile idiopathic arthritis (PJIA) AND

2)    Tried and failed or have contraindication/intolerance to Humira.


Limits

As a specialty drug, Xeljanz/Xeljanz XR is limited to a 30 day supply per fill.


Reference

1)    Xeljanz/Xeljanz XR prescribing information. Pfizer, Inc. New York, New York. May 2018.

2)    Clinical Pharmacology.  Xeljanz.  Accessed January 2019.

3)    Van Vollenhoven RF, Fleischmann R, Cohen S, et al.  Tofacitinib or adalimumab versus placebo in rheumatoid arthritis. NEJM, 2012.  367; 6:508-519.

4)    Fleishmann R, Kremer J, Cush J, et al.  Placebo-controlled trial of Tofacitinib monotherapy in rheumatoid arthritis. NEJM 2012.  367; 6:495-507.


Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.