Xeljanz · DIN 02423898 · 5mg · tablet
Limited Use — Reason for Use code 480, 589, 743 requiredMarketed · checked 2026-09-19
StatusLimited Use — Reason for Use code 480, 589, 743 required
Write on scriptLU code 480, 589, 743 (patient must meet the criteria below)
Patient paysPatient pays: program not supplied; amount cannot be determined.
Private plan unknown: ask. If yes, check its coverage and payer coordination; if no, see the public routes below.
Ontario Limited Use criteria — code 480, 589, 743
Reason for Use code 480
For the treatment of rheumatoid arthritis (RA) in patients who have severe active disease (greater than or equal to 5 swollen joints and rheumatoid factor positive and/or, anti-CCP positive, and/or radiographic evidence of rheumatoid arthritis) and have experienced failure, intolerance, or have a contraindication to adequate trials of disease-modifying anti-rheumatic drugs (DMARDs) treatment regimens, such as one of the following combinations of treatments:
A. i) Methotrexate (20mg/week) for at least 3 months, AND
ii) leflunomide (20mg/day) for at least 3 months, in addition to
iii) an adequate trial of at least one combination of DMARDs for 3 months; OR
B. i) Methotrexate (20mg/week) for at least 3 months, AND
ii) leflunomide in combination with methotrexate for at least 3 months; OR
C. i) Methotrexate (20mg/week), sulfasalazine (2g/day) and hydroxychloroquine (400mg/day) for at least 3 months. (Hydroxychloroquine is based by weight up to 400mg per day.)
Maintenance/Renewal:
After 12 months of treatment, maintenance therapy is funded for patients with objective evidence of at least a 20 percent reduction in swollen joint count and a minimum of improvement in 2 swollen joints over the previous year.
For renewals beyond the second year, the patient must demonstrate objective evidence of preservation of treatment effect.
Therapy must be prescribed by a rheumatologist or a physician with expertise in rheumatology.
The recommended dosing regimen is 5mg administered twice daily
Coverage limit:
LU Authorization Period: 1 year
Reason for Use code 589
For the treatment of ulcerative colitis disease in patients who meet the following criteria:
1. Moderate disease
a. Mayo score between 6 and 10 (inclusive) AND
b. Endoscopic* subscore of 2 AND
c. Failed 2 weeks of oral prednisone at daily doses greater than or equal to 40mg (or a 1 week course of IV equivalent)
OR
d. Stabilized with 2 weeks oral prednisone at daily doses greater than or equal to 40mg (or 1 week of IV equivalent) but demonstrated that the corticosteroid dose cannot be tapered despite 3 months of AZA/6MP (or where the use of immunosuppressants is contraindicated).
2. Severe disease
a. Mayo score greater than 10 AND
b. Endoscopy* subscore of greater than or equal to 2 AND
c. Failed 2 weeks of oral prednisone at daily doses greater than or equal to 40mg (or 1 week of IV equivalent)
OR
d. Stabilized with 2 weeks oral prednisone at daily doses greater than or equal to 40mg (or 1 week of IV equivalent) but demonstrated that the corticosteroid dose cannot be tapered despite 3 months of AZA/6MP (or where the use of immunosuppressants is contraindicated).
*The endoscopy procedure must be done within the 12 months prior to initiation of treatment.
The recommended dosing regimen for induction is 10mg twice daily for at least 8 weeks.
Maintenance/Renewal:
Maintenance therapy is funded for patients who meet the Ministry initiation criteria and whose disease is maintained at Mayo score less than 6 AND who demonstrate at least 50% reduction in the dose of prednisone compared with the starting dose following the first 6 months of treatment with tofacitinib or be off corticosteroids after the first year of treatment.
The recommended dosing regimen is 5mg twice daily.
Depending on therapeutic response; 10mg twice daily may also be used for maintenance in some patients. However, the lowest effective dose possible should be used for maintenance therapy to minimize adverse effects.
Coverage limit:
LU Authorization Period: 1 year
Reason for Use code 743
For the treatment of polyarticular juvenile idiopathic arthritis (pJIA) in patients who have active disease (greater than or equal to 3 swollen joints and greater than or equal to 5 active joints) despite a trial of optimal doses of methotrexate (i.e. 15mg/m2 per week) for at least 3 months. Optimal route of methotrexate to be determined by the clinician.
Maintenance/Renewal:
After 12 months of treatment, maintenance therapy is funded for patients with objective evidence of at least a 20 percent reduction in swollen joint count and a minimum of improvement in 2 swollen joints compared to baseline result prior to the start of treatment in the previous year.
For funding beyond the second year, the patient must demonstrate objective evidence of preservation of treatment effect.
Recommended dose:
In children weighing 40kg or more, 5mg administered orally twice a day.
Therapy must be prescribed by a rheumatologist or a prescriber with expertise in rheumatology.
Prescribers should be informed and stay current with a drug's official Health Canada approved product monograph including available dosage formats.
Coverage limit:
LU Authorization Period: 1 year
Savings card: RxHelp ONE lists XELJANZ (read 2026-09-10) — brand-name savings card, free; cannot be combined with another card on the same claim. (rxhelp.ca ↗)
1 brand, same coverage
Xeljanz · DIN 02423898
Manufacturer: Pfizer Canada Inc.; listing date 2016-12-22
Health Canada: Marketed since 2014-06-03 · brand XELJANZ · ATC L04AF01 TOFACITINIB · form Tablet · route Oral · ingredients TOFACITINIB (TOFACITINIB CITRATE) 5 MG · company Pfizer canada ulc · schedule Prescription
Ministry pays: $5.9897 per source unit.
Source explanation: The formulary price is what ODB pays; the cash price at the counter is set by the pharmacy.
Formulary data: Ontario extract of Aug 26, 2026 · Health Canada DPD extract of Sep 2, 2026 (Open Government Licence – Canada) · https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=90863 · Verify on the e-Formulary ↗ (DIN 02423898)
Source record
DIN 02423898: Xeljanz
Raw flags: sec12=Y, sec3=Y
Item: 923600003; group id 1038; item number 2389; lccId 00269; manufacturer id PFI
Source form: Tab; strength: 5mg
Recorded listing: Limited Use: paid only with a Reason for Use code and the criteria below
Source prices (unrounded): $24.7733; ministry $5.9897
Source: ODB odb-formulary-ed43-extract-2026-08-26.xml extract_date=2026-08-26 DIN=02423898
Health Canada DPD extract of Sep 2, 2026 (Open Government Licence – Canada) · https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=90863
Interchangeable products
Auro-Tofacitinib · DIN 02530007 · $5.9897
Jamp Tofacitinib · DIN 02522896 · $5.9897
PMS-Tofacitinib · DIN 02522799 · $5.9897
Sandoz Tofacitinib · DIN 02551691 · $5.9897
Taro-Tofacitinib · DIN 02511304 · $5.9897
Shortage status: not checked (no credentials)