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11 MG, 22 MG — TABLET, EXTENDED RELEASE 24 HR

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: Excel (XLSX) · Formulary date: Sep 23, 2026 · Checked: 6 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Generic Formulary	—	✓	—	ST Step therapy: XELJANZ,XELJANZ XR W/O USE OF BRAND XELJANZ, XELJANZ XR IN THE LAST 720 DAYS REQ PRIOR AUTHORIZATION