tofacitinib citrate

1mg — Solution

ANTIRHEUMATIC - ENZYME INHIBITORS

Also known as: tofacitinib citrate soln 1mg/ml; tabs 5mg, 10mg; tb24 11mg, 22mg
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Checked: 2 hours, 7 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Xeljanz Xr 		Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 2 hours, 7 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Basic Option 2026 Tier 4 - Preferred Specialty ✓ — — PA
BCBS Federal Standard Option 2026 Tier 4 - Preferred Specialty ✓ — — PA
BCBS Federal Standard Option 2026
via Xeljanz Xr 		Tier 5 - Non-Preferred Specialty ✓ — — PA
BCBS Federal Basic Option 2026
via Xeljanz Xr 		Tier 5 - Non-Preferred Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 2 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Value 2026
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Care 2026
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Local 2026
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 2 hours ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold 1500 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect myDiabetesCare Bronze
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 5500 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze RD 6000 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver 3500 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze RD 5000 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 3500 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 7000 HSA Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver 4400 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 5000 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver 3000 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 6500 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver CMS Standard
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD CMS Standard
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Gold CMS Standard
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze RD CMS Standard
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Gold RD CMS Standard
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze CMS Standard
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 2200 Indiv Med Deductible
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect myDiabetesCare Silver
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 2 hours ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Xeljanz Xr 		Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Xeljanz Xr 		Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Xeljanz Xr 		Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Longevity Health Plan (HMO I-SNP)
via Xeljanz Xr 		Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP)
via Xeljanz Xr 		Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Xeljanz Xr 		Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
PruittHealth Premier (HMO I-SNP)
via Xeljanz Xr 		Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
NHC Advantage (HMO I-SNP)
via Xeljanz Xr 		Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Plan I (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Plan II (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Vitality Plan (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Troy Medicare (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Senior Care (HMO I-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Advantage (HMO C-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Signature (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Freedom (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Liberty (HMO-POS)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Value Plus (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Prime (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Care (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (HMO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Xeljanz Xr 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
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