Medicare AdvantagePrior AuthHigh impact
Xeljanz and Xeljanz XR (tofacitinib) (Revised)
Humana·Rheumatology, Gastroenterology, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicare Advantage revised its prior authorization policy for Xeljanz (tofacitinib) effective January 1, 2026, with updates finalized June 24, 2026. The policy now requires prior authorization for five indications (psoriatic arthritis, rheumatoid arthritis, ulcerative colitis, polyarticular juvenile idiopathic arthritis, and ankylosing spondylitis) with specific age requirements and mandatory prior treatment, contraindication, or intolerance with two qualifying biologics or JAK inhibitors before Xeljanz can be approved. Billing teams must verify member eligibility against these criteria and obtain prior authorization before claims are submitted.
Action Required
By January 1, 2026 (or immediately if past this date): Billing and prior authorization teams must implement the following: (1) Update billing system and EMR to flag all Xeljanz and Xeljanz XR prescriptions as requiring prior authorization for Medicare Advantage members; (2) Create or update prior authorization request templates to verify: member diagnosis matches one of five covered indications, member age meets formulation-specific requirements (age 2+ for IR tablet/oral solution; age 18+ for XR tablet), and documentation of prior therapy/contraindication/intolerance with two specific biologics from the approved list for each indication; (3) Train prior authorization and billing staff on indication-specific approval criteria (e.g., rheumatoid arthritis requires two of: adalimumab products, Enbrel, or Rinvoq; psoriatic arthritis requires two of: adalimumab, Enbrel, Cosentyx, ustekinumab products, Skyrizi, Rinvoq, or Tremfya); (4) Providers must submit clinical documentation with each prior authorization request proving prior therapy attempts, contraindications, or intolerances; (5) Update claim submission workflows to require documented prior authorization approval before billing. Consequence: Claims submitted without prior authorization approval will be denied by Humana Medicare Advantage.