Varies by plan

Does Devoted Health require prior authorization for Xeljanz?

Prior authorization for Xeljanz differs across Devoted Health's Medicare Part D plans and product strengths — 4 of 5 Xeljanz products in the corpus appear on their formularies, and the requirement is not uniform. Check the member's specific plan.

Some plans require authorization and others do not. The member's specific plan decides.

This drug does not appear on any of this payer's Medicare Part D formularies. That means it is NOT COVERED under those plans — which is a different and generally worse outcome than requiring prior authorization. An exception or formulary-exception request may still be possible.

By product strength

RxNorm product	Plans covering	Require prior auth	Qty limit	Status
tofacitinib 5 MG Oral Tablet [Xeljanz]1357547	132 / 415	132	132	Prior authorization required
24 HR tofacitinib 11 MG Extended Release Oral Tablet [Xeljanz]1741049	132 / 415	132	132	Prior authorization required
tofacitinib 10 MG Oral Tablet [Xeljanz]2048568	132 / 415	132	132	Prior authorization required
24 HR tofacitinib 22 MG Extended Release Oral Tablet [Xeljanz]2273115	132 / 415	132	132	Prior authorization required
tofacitinib 1 MG/ML Oral Solution [Xeljanz]2478437	0 / 415	0	0	Not on formulary

Product names come from RxNorm (U.S. National Library of Medicine).

Plan-by-plan detail — tofacitinib 5 MG Oral Tablet [Xeljanz]

Xeljanz has 5 products in the corpus; this table is for tofacitinib 5 MG Oral Tablet [Xeljanz], the one carried on the most plans. The product table above covers every strength.

Plan	Contract	Tier	Prior auth	Step therapy	Qty limit
DEVOTED C-SNP 011 AZ (HMO C-SNP)	H8173-011	5	Yes	No	Yes
DEVOTED C-SNP 046 TX (HMO C-SNP)	H7993-046	5	Yes	No	Yes
DEVOTED C-SNP PREMIUM 014 AZ (HMO C-SNP)	H8173-014	5	Yes	No	Yes
DEVOTED C-SNP PREMIUM 016 TN (HMO C-SNP)	H7605-016	5	Yes	No	Yes
DEVOTED CHOICE 001 AL (PPO)	H9888-001	5	Yes	No	Yes
DEVOTED CHOICE 001 CO (PPO)	H4808-001	5	Yes	No	Yes
DEVOTED CHOICE 001 OH (PPO)	H2526-001	5	Yes	No	Yes
DEVOTED CHOICE 001 SC (PPO)	H7028-001	5	Yes	No	Yes
DEVOTED CHOICE 002 AL (PPO)	H9888-002	5	Yes	No	Yes
DEVOTED CHOICE 002 AZ (PPO)	H6586-002	5	Yes	No	Yes
DEVOTED CHOICE 002 CO (PPO)	H4808-002	5	Yes	No	Yes
DEVOTED CHOICE 003 AZ (PPO)	H6586-003	5	Yes	No	Yes
DEVOTED CHOICE 004 HI (PPO)	H2686-004	5	Yes	No	Yes
DEVOTED CHOICE 004 HI (PPO)	H2686-004	5	Yes	No	Yes
DEVOTED CHOICE 007 TN (PPO)	H9231-007	5	Yes	No	Yes
DEVOTED CHOICE 010 TN (PPO)	H9231-010	5	Yes	No	Yes
DEVOTED CHOICE 015 FL (PPO)	H9884-015	5	Yes	No	Yes
DEVOTED CHOICE 015 TN (PPO)	H9231-015	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 001 TX (PPO)	H6813-001	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 002 SC (PPO)	H7028-002	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 002 TN (PPO)	H9231-002	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 003 CO (PPO)	H4808-003	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 003 PA (PPO)	H6018-003	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 005 HI (PPO)	H2686-005	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 005 HI (PPO)	H2686-005	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 005 TN (PPO)	H9231-005	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 006 AZ (PPO)	H6586-006	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 006 TN (PPO)	H9231-006	5	Yes	No	Yes
DEVOTED CHOICE GIVEBACK 013 FL (PPO)	H9884-013	5	Yes	No	Yes
DEVOTED CHOICE PREMIUM 002 OR (PPO)	H7199-002	5	Yes	No	Yes
DEVOTED CHOICE PREMIUM 002 PA (PPO)	H6018-002	5	Yes	No	Yes
DEVOTED CHOICE PREMIUM 006 HI (PPO)	H2686-006	5	Yes	No	Yes
DEVOTED CHOICE PREMIUM 006 HI (PPO)	H2686-006	5	Yes	No	Yes
DEVOTED CORE 001 AL (HMO)	H3080-001	5	Yes	No	Yes
DEVOTED CORE 001 AZ (HMO)	H8173-001	5	Yes	No	Yes
DEVOTED CORE 001 CO (HMO)	H7147-001	5	Yes	No	Yes
DEVOTED CORE 001 FL (HMO)	H1290-001	5	Yes	No	Yes
DEVOTED CORE 001 NC (HMO)	H5299-001	5	Yes	No	Yes
DEVOTED CORE 001 OH (HMO)	H2697-001	5	Yes	No	Yes
DEVOTED CORE 001 OR (HMO)	H2923-001	5	Yes	No	Yes
DEVOTED CORE 001 SC (HMO)	H3041-001	5	Yes	No	Yes
DEVOTED CORE 001 TN (HMO)	H7605-001	5	Yes	No	Yes
DEVOTED CORE 002 FL (HMO)	H1290-002	5	Yes	No	Yes
DEVOTED CORE 003 FL (HMO)	H1290-003	5	Yes	No	Yes
DEVOTED CORE 003 TX (HMO)	H7993-003	5	Yes	No	Yes
DEVOTED CORE 004 CO (HMO)	H7147-004	5	Yes	No	Yes
DEVOTED CORE 004 OH (HMO)	H2697-004	5	Yes	No	Yes
DEVOTED CORE 004 TN (HMO)	H7605-004	5	Yes	No	Yes
DEVOTED CORE 004 TX (HMO)	H7993-004	5	Yes	No	Yes
DEVOTED CORE 005 FL (HMO)	H1290-005	5	Yes	No	Yes
DEVOTED CORE 007 AZ (HMO)	H8173-007	5	Yes	No	Yes
DEVOTED CORE 007 OH (HMO)	H2697-007	5	Yes	No	Yes
DEVOTED CORE 007 TN (HMO)	H7605-007	5	Yes	No	Yes
DEVOTED CORE 007 TX (HMO)	H7993-007	5	Yes	No	Yes
DEVOTED CORE 009 TN (HMO)	H7605-009	5	Yes	No	Yes
DEVOTED CORE 010 TN (HMO)	H7605-010	5	Yes	No	Yes
DEVOTED CORE 016 AZ (HMO)	H8173-016	5	Yes	No	Yes
DEVOTED CORE 023 PA (HMO)	H6852-023	5	Yes	No	Yes
DEVOTED CORE 025 FL (HMO)	H1290-025	5	Yes	No	Yes
DEVOTED CORE 027 FL (HMO)	H1290-027	5	Yes	No	Yes
DEVOTED CORE 029 FL (HMO)	H1290-029	5	Yes	No	Yes
DEVOTED CORE 036 FL (HMO)	H1290-036	5	Yes	No	Yes
DEVOTED CORE 036 FL (HMO)	H1290-036	5	Yes	No	Yes
DEVOTED CORE 046 FL (HMO)	H1290-046	5	Yes	No	Yes
DEVOTED CORE 050 FL (HMO)	H1290-050	5	Yes	No	Yes
DEVOTED DUAL 004 AL (HMO D-SNP)	H3080-004	5	Yes	No	Yes
DEVOTED DUAL 007 AL (HMO D-SNP)	H3080-007	5	Yes	No	Yes
DEVOTED DUAL 007 CO (HMO D-SNP)	H7147-007	5	Yes	No	Yes
DEVOTED DUAL 009 NC (HMO D-SNP)	H5299-009	5	Yes	No	Yes
DEVOTED DUAL 011 OH (HMO D-SNP)	H2697-011	5	Yes	No	Yes
DEVOTED DUAL 019 FL (HMO D-SNP)	H1290-019	5	Yes	No	Yes
DEVOTED DUAL 020 FL (HMO D-SNP)	H1290-020	5	Yes	No	Yes
DEVOTED DUAL 021 FL (HMO D-SNP)	H1290-021	5	Yes	No	Yes
DEVOTED DUAL 022 FL (HMO D-SNP)	H1290-022	5	Yes	No	Yes
DEVOTED DUAL 023 FL (HMO D-SNP)	H1290-023	5	Yes	No	Yes
DEVOTED DUAL 024 FL (HMO D-SNP)	H1290-024	5	Yes	No	Yes
DEVOTED DUAL 033 FL (HMO D-SNP)	H1290-033	5	Yes	No	Yes
DEVOTED DUAL 034 FL (HMO D-SNP)	H1290-034	5	Yes	No	Yes
DEVOTED DUAL 039 FL (HMO D-SNP)	H1290-039	5	Yes	No	Yes
DEVOTED DUAL 041 FL (HMO D-SNP)	H1290-041	5	Yes	No	Yes
DEVOTED DUAL 043 FL (HMO D-SNP)	H1290-043	5	Yes	No	Yes
DEVOTED DUAL FULL 077 FL (HMO D-SNP)	H1290-077	5	Yes	No	Yes
DEVOTED DUAL FULL 078 FL (HMO D-SNP)	H1290-078	5	Yes	No	Yes
DEVOTED DUAL FULL 079 FL (HMO D-SNP)	H1290-079	5	Yes	No	Yes
DEVOTED DUAL FULL 080 FL (HMO D-SNP)	H1290-080	5	Yes	No	Yes
DEVOTED DUAL FULL 081 FL (HMO D-SNP)	H1290-081	5	Yes	No	Yes
DEVOTED DUAL FULL 082 FL (HMO D-SNP)	H1290-082	5	Yes	No	Yes
DEVOTED DUAL FULL 083 FL (HMO D-SNP)	H1290-083	5	Yes	No	Yes
DEVOTED DUAL PLUS 003 AL (HMO D-SNP)	H3080-003	5	Yes	No	Yes
DEVOTED DUAL PLUS 003 CO (HMO D-SNP)	H7147-003	5	Yes	No	Yes
DEVOTED DUAL PLUS 006 AL (HMO D-SNP)	H3080-006	5	Yes	No	Yes
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	H5299-006	5	Yes	No	Yes
DEVOTED DUAL PLUS 010 OH (HMO D-SNP)	H2697-010	5	Yes	No	Yes
DEVOTED DUAL PLUS 042 FL (HMO D-SNP)	H1290-042	5	Yes	No	Yes
DEVOTED DUAL PLUS 052 FL (HMO D-SNP)	H1290-052	5	Yes	No	Yes
DEVOTED DUAL PLUS 053 FL (HMO D-SNP)	H1290-053	5	Yes	No	Yes
DEVOTED DUAL PLUS 054 FL (HMO D-SNP)	H1290-054	5	Yes	No	Yes
DEVOTED DUAL PLUS 055 FL (HMO D-SNP)	H1290-055	5	Yes	No	Yes
DEVOTED GIVEBACK 002 AL (HMO)	H3080-002	5	Yes	No	Yes
DEVOTED GIVEBACK 002 NC (HMO)	H5299-002	5	Yes	No	Yes

Showing 100 of 132 covering plans.

Source

Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File

Effective: 2026-06-30
Retrieved: 2026-07-19
SHA-256: e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae

We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.

Xeljanz at other payers

Or see Xeljanz across every payer at once.

Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.