Medicare AdvantagePrior AuthHigh impact
Xeljanz and Xeljanz XR (tofacitinib) (Revised)
Humana·Rheumatology, Gastroenterology, Dermatology·Medicare Advantage
We identified it
Jul 2, 2026
Summary
This is a revised Prior Authorization policy for Xeljanz and Xeljanz XR (tofacitinib) affecting Medicare Advantage members. The policy update requires prior authorization review before these medications can be dispensed. Specific clinical criteria and effective date cannot be determined from the summary-only content provided.
Action Required
Immediately: Billing and clinical teams must obtain the full policy document from the source URL (https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a56a5fe) to determine: (1) specific effective date, (2) clinical criteria for prior authorization approval, (3) required documentation, and (4) affected NDC codes or HCPCS codes for tofacitinib. Update prior authorization workflows in billing system to require PA submission for Xeljanz/Xeljanz XR before claims are submitted to Humana Medicare Advantage plans. Train pharmacy and clinical staff on new requirements. Failure to obtain prior authorization will result in claim denials and potential member out-of-pocket costs. Verify if this revised policy supersedes any previous tofacitinib authorization guidance.