The March 15, 2026 revision to Cigna’s MDC 06 (IP0682) consolidates Rinvoq (upadacitinib ER tablets) coverage criteria for Crohn’s disease and ulcerative colitis, clarifying 6-month approvals for new starts and 1-year approvals for established therapy (≥6 months). Initial approvals require adults (≥18) to have an inadequate response to, or intolerance of, a 3-month trial of at least one TNF‑alpha inhibitor, and prescribing must involve a gastroenterologist. Continued coverage requires objective evidence of benefit (e.g., fecal calprotectin, CRP, imaging, endoscopy, or corticosteroid dose reduction) or documented symptomatic improvement versus baseline. Rinvoq oral solution (LQ) is not an approved formulation under this policy; only extended‑release tablets are covered.
March 15, 2026 Revision: Rinvoq Coverage Consolidation
Summary of changes in the March 15, 2026 revision to IP0682
This revision clarifies and consolidates coverage criteria for Rinvoq (upadacitinib extended-release tablets) across inflammatory bowel disease and related indications within the MDC 06: Gastroenterology policy. The policy explicitly states approval pathways for both Crohn's disease and ulcerative colitis, separating initial therapy criteria (6-month approvals) from continuation/established therapy criteria (1-year approvals) and specifies required documentation of prior tumor necrosis factor inhibitor (TNFi) exposure or intolerance.
The revision also reiterates that Rinvoq LQ oral solution is not an approved formulation for these indications under the policy — approvals are for extended-release tablets only. Objective response measures that can be used to support continued authorization (e.g., fecal calprotectin, C-reactive protein, imaging, endoscopy, and corticosteroid dose reduction) are emphasized in the continuation criteria.
Crohn's Disease: Initial (6-month) vs Established (1-year) Criteria
Specific initial and continuation approval windows for Crohn's disease
For Crohn's disease the policy defines two distinct approval pathways. Under Initial Therapy, Rinvoq extended-release tablets may be approved for 6 months for adults (≥ 18 years) who have had an inadequate response or intolerance to at least one TNFi after a 3-month trial, or who were unable to tolerate a 3-month trial of a TNFi. The prescribing clinician must be a gastroenterologist or consult with one.
Under Currently Receiving Rinvoq, the policy provides a 1-year approval for patients already established on therapy for at least 6 months. Continued coverage requires either objective evidence of benefit (examples include fecal or serum biomarkers, imaging, endoscopy, or corticosteroid dose reduction) or symptomatic improvement compared with baseline (e.g., pain, fatigue, stool frequency, or bleeding). The policy refers to an appendix for examples of TNFis used for Crohn's disease.
Ulcerative Colitis: Entry Requirements and Objective Response Criteria
Mirrored criteria and objective response measures for Ulcerative Colitis
The ulcerative colitis criteria closely mirror those for Crohn's disease. For Initial Therapy, adults (≥ 18 years) require a 3-month trial of at least one TNFi (or documented intolerance to a 3-month trial) and the medication must be prescribed by or in consultation with a gastroenterologist; approvals are for 6 months. For patients already on Rinvoq (established ≥ 6 months), a 1-year approval is available if there is objective evidence of clinical benefit or symptomatic improvement versus baseline.
Objective measures listed as acceptable evidence for continued approval include fecal markers (e.g., fecal calprotectin), serum markers (e.g., C-reactive protein), endoscopic assessment, and/or reduction in corticosteroid dosing. Symptom-based improvements can include decreased stool frequency, rectal bleeding, pain, or fatigue.
Guideline Context and `Rinvoq`'s Role Among Advanced Therapies
Positioning of Rinvoq relative to guideline recommendations and other advanced therapies
The policy cites recently updated gastroenterology guidelines (ACG 2025 and AGA 2025) that include Rinvoq among recommended advanced therapies for Crohn's disease, noting that both organizations recommend upfront use of advanced therapies rather than traditional step-up approaches. Advanced therapy options enumerated in the policy include TNF inhibitors, Entyvio (vedolizumab), IL-23 inhibitors, IL-12/23 inhibitors, and Rinvoq.
For ulcerative colitis the policy references the AGA (2024) and ACG (2019) guidance recognizing all FDA-approved advanced therapies for moderate to severe disease and recommending initiation with advanced therapies and/or immunomodulators. The policy therefore aligns Rinvoq with these recognized advanced therapeutic options while maintaining payer-specific prior-exposure and documentation criteria.
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