Medicare AdvantagePrior AuthHigh impact
Xeljanz and Xeljanz XR (tofacitinib)
Humana·Rheumatology, Gastroenterology, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has implemented a new prior authorization policy for Xeljanz/Xeljanz XR (tofacitinib) effective January 1, 2026. The policy requires prior authorization for five indications (psoriatic arthritis, rheumatoid arthritis, ulcerative colitis, polyarticular juvenile idiopathic arthritis, and ankylosing spondylitis) with mandatory documentation of failed or contraindicated therapy with two specific biologics before approval. Billing teams must update systems to enforce these prior authorization requirements and verify member age/diagnosis criteria before claim submission.
Action Required
By December 31, 2025: Billing team must update prior authorization system to require prior auth for all Xeljanz and Xeljanz XR prescriptions for Medicare Advantage members. Providers must document that the member meets ALL three criteria for their specific indication: (1) confirmed diagnosis (active psoriatic arthritis, moderate-to-severe rheumatoid arthritis, moderate-to-severe ulcerative colitis, active polyarticular juvenile idiopathic arthritis, or active ankylosing spondylitis); (2) appropriate age (18+ for most indications, 2+ for IR tablet and oral solution formulations); (3) prior therapy with or contraindication/intolerance to TWO biologics from the indication-specific list (adalimumab products, Enbrel, Cosentyx, Stelara/Otulfi/Yesintek, Skyrizi, Rinvoq, or Tremfya as applicable). Billing team must verify documentation before submitting claims. Intake staff must add prior auth requirement to encounter forms and patient communication. Failure to obtain prior authorization will result in claim denials. Route all Xeljanz requests through prior authorization workflow before claim submission.