Blue Cross Blue Shield - Iowa Rinvoq Prior Auth

Coverage Criteria by Indication

Rheumatoid arthritis (RA)

Authorization may be granted when the following are met:

RA initial/continuation: 1) Adult member with moderately to severely active rheumatoid arthritis; AND 2) Member has experienced an inadequate response or intolerance to at least one tumor necrosis factor (TNF) inhibitor OR member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for RA; AND 3) For continuation, member achieves or maintains a positive clinical response as evidenced by ≥20% improvement from baseline in tender joint count, swollen joint count, pain, or disability.>=20% improvement

Authorization for 12 months

Psoriatic arthritis (PsA)

Authorization may be granted when the following are met:

PsA: 1) Member age ≥2 years with active psoriatic arthritis; AND 2) Member has experienced an inadequate response or intolerance to at least one TNF inhibitor OR (for adults) has previously received a biologic (other than a TNF inhibitor) or targeted synthetic agent indicated for PsA.

Authorization for 12 months

Atopic dermatitis

Authorization may be granted when ALL of the following are met:

Atopic dermatitis initial: A. Affected body surface area ≥10% OR involvement of crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas); AND B. Either 1) inadequate treatment response within the past 180 days to a medium‑to‑super‑high potency topical corticosteroid or a topical calcineurin inhibitor, OR 2) documentation that these topical therapies are not advisable; AND C. Inadequate response to, intolerance of, or contraindication to a systemic drug (e.g., cyclosporine, azathioprine, methotrexate, mycophenolate) or a biologic indicated for atopic dermatitis, or documentation that systemic therapies are not advisable.180 days for topical trial

Initial authorization up to 4 months

Ulcerative colitis (UC) and Crohn's disease (CD)

Authorization may be granted when ALL of the following are met:

IBD: 1) Member with moderately to severely active ulcerative colitis or moderately to severely active Crohn's disease; AND 2) Member has experienced an inadequate response or intolerance to at least one TNF inhibitor OR (if TNF blockers are clinically inadvisable) has previously received at least one approved systemic therapy for the condition.

Authorization for 12 months

Ankylosing spondylitis and nr-axSpA

Authorization may be granted when ALL of the following are met:

AS/nr-axSpA: 1) Adult member with active ankylosing spondylitis or active non‑radiographic axial spondyloarthritis with objective signs of inflammation; AND 2) Member has experienced an inadequate response or intolerance to one or more TNF inhibitors OR has previously received a biologic (other than a TNF inhibitor) or targeted synthetic agent indicated for this condition.

Authorization for 12 months

Polyarticular juvenile idiopathic arthritis (pJIA)

Authorization may be granted when ALL of the following are met:

pJIA: 1) Member age ≥2 years with active polyarticular juvenile idiopathic arthritis; AND 2) Member has experienced an inadequate response or intolerance to one or more TNF inhibitors OR has previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for pJIA.

Authorization for 12 months

Giant cell arteritis (GCA)

Authorization may be granted when ALL of the following are met:

GCA: A. Diagnosis of giant cell arteritis confirmed by temporal artery biopsy OR by cross‑sectional vascular imaging (ultrasonography, PET, CT, MRI, or angiography); AND B. Member meets one of the following: 1) Inadequate response to glucocorticoids (e.g., relapse during taper or persistent symptoms) OR 2) Glucocorticoid‑related adverse effects or significant comorbidities requiring a steroid‑sparing agent.

Authorization for 12 months

Giant Cell Arteritis (initial)

Authorization of 12 months may be granted when ALL of the following are met:

GCA initial: Member is an adult with diagnosis of giant cell arteritis confirmed by temporal artery biopsy OR cross‑sectional vascular imaging; AND member has inadequate response to glucocorticoids (relapse during taper or persistent symptoms) OR has glucocorticoid‑related adverse effects or significant comorbidities requiring a steroid‑sparing agent.

From chunk 18

Giant Cell Arteritis (continuation)

Authorization of 12 months may be granted for members using Rinvoq for GCA who have demonstrated a positive clinical response, as evidenced by:

GCA response: Improvement in one or more GCA symptoms (new or worsening headache, scalp tenderness, jaw or tongue claudication, acute visual symptoms, limb claudication, constitutional symptoms, or polymyalgia rheumatica symptoms) OR reduction in glucocorticoid use.

From chunk 29

Rheumatoid Arthritis

Authorization of 12 months may be granted when ALL of the following are met:

RA continuation/response: Member has moderately to severely active rheumatoid arthritis and achieves or maintains a positive clinical response evidenced by at least 20% improvement from baseline in tender joint count, swollen joint count, pain, or disability.>=20% improvement

From chunk 19

Psoriatic Arthritis

Authorization of 12 months may be granted when ALL of the following are met:

PsA response: Member has active psoriatic arthritis and achieves or maintains a positive clinical response evidenced by low disease activity or improvement in any of the following from baseline: number of swollen joints, number of tender joints, dactylitis, enthesitis, axial disease, skin and/or nail involvement, functional status, or C‑reactive protein (CRP).

From chunk 20

Atopic Dermatitis

Authorization of 12 months may be granted when ALL of the following are met:

AD response: Member age ≥12 years with moderate‑to‑severe atopic dermatitis who achieves or maintains a positive clinical response evidenced by low disease activity (clear or almost clear skin) or improvement in signs/symptoms (e.g., redness, itching, oozing/crusting).age >=12

From chunk 21; initial topical/systemic trial requirements in chunk 13 apply for initiation

Ulcerative Colitis

Authorization of 12 months may be granted when ONE of the following is met:

UC remission: Member achieves or maintains remission for moderately to severely active ulcerative colitis.

From chunk 22

UC response: Member achieves or maintains a positive clinical response evidenced by improvement from baseline in stool frequency, rectal bleeding, urgency, C‑reactive protein (CRP), fecal calprotectin, mucosal appearance on endoscopy/CTE/MRE/intestinal ultrasound, or improvement on disease activity scoring tools (e.g., UCEIS, Mayo).

From chunk 22

Ankylosing Spondylitis / axial SpA

Authorization of 12 months may be granted when ALL of the following are met:

AS/axSpA response: Member has active ankylosing spondylitis or axial spondyloarthritis and achieves or maintains a positive clinical response evidenced by low disease activity or improvement from baseline in functional status, total spinal pain, inflammation (e.g., morning stiffness), swollen/tender joints, or C‑reactive protein (CRP).

From chunk 23

Crohn's Disease

Authorization of 12 months may be granted when ONE of the following is met:

CD remission: Member achieves or maintains remission for moderately to severely active Crohn's disease.

From chunk 24

CD response: Member achieves or maintains a positive clinical response evidenced by improvement from baseline in abdominal pain/tenderness, diarrhea, body weight, abdominal mass, or hematocrit.

From chunk 24

Polyarticular juvenile idiopathic arthritis

Authorization of 12 months may be granted when ALL of the following are met:

pJIA response: Member (including new members) age ≥2 years using Rinvoq or Rinvoq LQ for active polyarticular juvenile idiopathic arthritis and who achieve or maintain a positive clinical response as evidenced by improvement in number of joints with active arthritis, number of joints with limitation of movement, or functional ability.

From chunk 28

This medical policy may not apply to Federal Employee Program (FEP) members. Benefit determinations for FEP members are made by the Federal Employee Program and are governed by the applicable FEP contract rather than this Wellmark policy.

Prior to initiation and during treatment, document a negative tuberculosis (TB) test within the prior 12 months for persons who are biologic- or targeted-synthetic–naïve. If TB screening is positive, perform further evaluation (for example, chest x-ray) to exclude active disease. Do not administer the requested medication to members with active tuberculosis infection. If latent TB is identified, start appropriate TB treatment before initiating the requested medication. Additionally, concomitant use of the requested medication with another biologic, targeted synthetic drug, or a potent immunosuppressant (e.g., azathioprine or cyclosporine) for the same indication is prohibited.

Indications that are not listed as covered—i.e., those outside the FDA-approved indications and recognized compendial uses specified in this policy—are not considered covered unless the approval criteria are met and the member has no applicable exclusions. Coverage is provided only when the specific clinical and documentation requirements in this policy are satisfied.

Prior Authorization, Documentation, and Prescribing Requirements

Prior Authorization

Prior authorization required

Prior authorization is required; typical initial authorizations are for up to 12 months for most indications (4 months initial for atopic dermatitis). Initial and continuation requests must include supporting documentation as outlined below. Prescriptions must conform to quantity limits (Rinvoq: 30 tablets per 30 days). Concomitant use with another biologic, targeted synthetic agent, or potent immunosuppressant for the same indication is prohibited.

Prior authorization required for Rinvoq; initial approvals: generally up to 12 months (except moderate-to-severe atopic dermatitis initial approval up to 4 months when criteria met).
Quantity limit: Rinvoq — 30 tablets per 30 days.
Do not prescribe concurrently with another biologic, targeted synthetic drug, or potent immunosuppressant (e.g., azathioprine, cyclosporine) for the same indication.

Documentation Required

Required documentation for prior authorization

Submit chart notes, medical record documentation, or claims history supporting prior therapies tried and the member's response when applicable. For continuation requests, provide chart notes or medical records demonstrating a positive clinical response or maintenance of response as specified by indication.

Procedures, Codes, and Key Measures

Atopic dermatitis body surface area

Atopic dermatitis BSA threshold>= 10% body surface area

Crucial body areasHands, feet, face, neck, scalp, genitals/groin, intertriginous areas

Authorization duration (initial) for ADUp to 4 months when criteria met

Topical therapy requirement windowInadequate response to a medium‑to‑super‑high potency topical corticosteroid or topical calcineurin inhibitor within past 180 days (or these are not advisable)

Key Definitions and Clinical Thresholds

Confirmed giant cell arteritis (GCA)

Definition of confirmed GCADiagnosis confirmed by temporal artery biopsy consistent with GCA OR cross‑sectional vascular imaging (ultrasonography, PET, CT, MRI, or angiography)

Glucocorticoid treatment failureInadequate response to glucocorticoids (e.g., relapse during taper or persistent symptoms)

Steroid‑sparing indicationGlucocorticoid‑related adverse effects or significant comorbidities requiring a steroid‑sparing agent

Moderate-to-severe atopic dermatitis criteria

Moderate‑to‑severe AD criteria — BSA>=10% body surface area

Moderate‑to‑severe AD criteria — crucial areasInvolvement of hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas

Drug Background and Scope

Upadacitinib (Rinvoq) and its long-acting formulation Rinvoq LQ are targeted synthetic agents approved for multiple immune-mediated inflammatory conditions. This policy aligns coverage with FDA labeling and compendial uses and defines indication-specific prior authorization, step-therapy expectations, and documentation requirements to support initial and continuation approvals.

OpenPayer

Rinvoq (upadacitinib) and Rinvoq LQ: Prior Authorization and Coverage Criteria

Coverage Criteria by Indication

Prior Authorization, Documentation, and Prescribing Requirements

Procedures, Codes, and Key Measures

Key Definitions and Clinical Thresholds

Drug Background and Scope