Cigna prior authorization policy governing medical necessity criteria, initial and continuation approval durations, prescribing specialist requirements, contraindicated combinations, and covered FDA indications for Rinvoq (extended-release tablets) and Rinvoq LQ (oral solution) across multiple inflammatory conditions.
Policy Summary
PayerCigna
PolicyRinvoq/Rinvoq LQ Prior Authorization Policy
Policy CodePolicy IP0682
Change TypeRevisions including added GCA indication and updated corticosteroid requirement
Effective DateJul 15, 2025
Next Review Date
Key ActionPrior Authorization is required for benefit coverage of Rinvoq/Rinvoq LQ; approvals provided for specified durations and prescriber specialty requirements must be met.
POLICY UPDATE CHANGES
New policy created on 11/01/2024.
Atopic Dermatitis: Added Ebglyss (lebrikizumab-lbkz) and Nemluvio (nemolizumab-ilto) as examples of systemic therapies and as examples of biologic immunomodulators not allowed concurrently with Rinvoq.
Removed COVID-19 from Conditions Not Covered and added Giant Cell Arteritis indication.
Giant Cell Arteritis: Changed requirement to 'tried or currently be taking a systemic corticosteroid, unless systemic corticosteroids are contraindicated.'
9FDA-Approved Indications Covered
1Indication with shorter initial approval (Atopic Dermatitis)
6Typical initial approval months for most indications
12Drugs listed
Coverage Summary
coverage_stance:covered_with_criteria; Policy Number IP0682; Effective/Last Review Date: 07/15/2025. Rinvoq (upadacitinib extended-release tablets) and Rinvoq LQ (upadacitinib oral solution) are covered with prior authorization when the FDA‑approved indication criteria are met. Initial approval requires prescription by or in consultation with an appropriate specialist for the condition being treated, and approvals are provided for the durations specified in the policy. The policy aligns coverage with FDA‑approved indications and the criteria include requirement for prior trials (e.g., tumor necrosis factor inhibitor or systemic therapy trials) or documented intolerance when specified in the indication‑specific criteria.
Thresholds & quick facts
Initial approval durations3 months for Atopic Dermatitis; 6 months for most other initial therapy indications
Established on therapy (continuation)≥ 90 days for Atopic Dermatitis; ≥ 6 months for most other indications
FDA-Approved Indications Covered9 indications
Drugs listed in appendix12 drugs listed
Initial Therapy Criteria
General Prior Authorization and Prescriber Requirement
ALL of the following
Prior Authorization required for benefit coverage of Rinvoq/Rinvoq LQ
Initial approval requires Rinvoq/Rinvoq LQ to be prescribed by or in consultation with a physician who specializes in the condition being treated
Use of preferred products required before approval per referenced Preferred Specialty Management Policy (PSM001/PSM002/PSM017)
Refer to Inflammatory Conditions Preferred Specialty Management Policy for specific preferred product criteria.
Covered Indications and Specific Criteria (FDA-Approved Indications)
Rinvoq/Rinvoq LQ considered medically necessary when ONE of the indication-specific branches (1-9) is met. Each branch retains A) Initial Therapy and B) Currently Receiving logic with age limits, required prior trials, prescriber specialty, and approval durations.
Continuation Therapy Criteria
Continuation Criteria
Continuation (Currently Receiving) branches for each FDA-approved indication. Preserve established-on-therapy duration, required evidence of beneficial clinical response (objective measures examples per indication) and symptomatic improvement, and renewal approval duration of 1 year.
1. Ankylosing Spondylitis - Continuation
B) Currently Receiving: Patient has been established on therapy for at least 6 months
A patient with <6 months or restarting is reviewed under Initial Therapy
Response evidence
When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline
Operational prohibitions and denial risk: non‑FDA‑approved uses and concurrent use with other JAKis, biologics, or potent immunosuppressants are considered not medically necessary and may be denied.
ALL of the following
Prohibition: non‑FDA‑approved indications: Use of Rinvoq/Rinvoq LQ for non‑FDA‑approved indications is considered not medically necessary and may be denied
Prohibition: concurrent JAK inhibitors or biologics: Rinvoq/Rinvoq LQ is not recommended and concurrent use with other JAK inhibitors or with biologics is considered not medically necessary and may be denied
Examples of biologic immunomodulators listed in policy (eg, Dupixent, Adbry, Ebglyss, Nemluvio)
PDE4 inhibitor; listed indications include PsO, PsA; noted as oral therapy/targeted small molecule
Cibinqo (abrocitinib)
JAK pathway inhibitor; listed indication AD
Olumiant (baricitinib)
JAK pathway inhibitor; listed indications RA, AA
Litfulo (ritlecitinib)
JAK pathway inhibitor; listed indication AA
Leqselvi (deuruxolitinib)
JAK pathway inhibitor; listed indication AA
Rinvoq (upadacitinib) ER tablets
JAK pathway inhibitor; listed indications include AD, AS, nr-axSpA, RA, PsA, CD, UC
Rinvoq LQ (upadacitinib oral solution)
JAK pathway inhibitor; listed indications PsA, PJIA
Sotyktu (deucravacitinib)
TYK2 inhibitor; listed indication PsO
Xeljanz (tofacitinib) tablets/oral solution
JAK pathway inhibitor; listed indications RA, PJIA, PsA, UC
Xeljanz XR (tofacitinib extended-release)
JAK pathway inhibitor; listed indications RA, PsA, UC
1–10 of 13
1/2
Provider Actions & Requirements
Prior Authorization
Prior Authorization required
Prior Authorization is required for benefit coverage of Rinvoq/Rinvoq LQ; approvals provided for specified durations and prescriber specialty requirements must be met.
Providers must document prior trials of specified therapies (for example, 3-month TNFi trials for many indications; 4-month systemic therapy trials for atopic dermatitis) and must document objective or symptomatic clinical response compared with baseline to support continuation approvals.
Dosing / Utilization Notes
Dosage, frequency, duration, and site of care must be reasonable, clinically appropriate, and evidence‑supported. Receipt of sample product does not satisfy criteria requirements for coverage. Rinvoq LQ oral solution is only indicated for polyarticular juvenile idiopathic arthritis (PJIA) and psoriatic arthritis in patients 2 to < 18 years of age and is not substitutable with Rinvoq extended‑release tablets. Rinvoq/Rinvoq LQ are not recommended to be used in combination with other JAK inhibitors, biologics, or other potent immunosuppressants (for example, azathioprine, cyclosporine); such concurrent use is considered not medically necessary. When applicable, use of preferred products is required before approval per the referenced Preferred Specialty Management policies (PSM001/PSM002/PSM017).
Clinical Evidence & References
Evidence source: Prescribing information — Rinvoq tablets/Rinvoq LQ oral solution, AbbVie; April 2024. FDA‑approved indications and referenced objective measures in the criteria are based on the product prescribing information.
Background
Rinvoq is a Janus kinase (JAK) inhibitor with multiple FDA‑approved indications across inflammatory conditions. This policy aligns coverage with FDA indications, requires specialist involvement for initiation, and generally requires prior trials of tumor necrosis factor inhibitors or specified systemic therapies (or documented intolerance) where indicated. An appendix lists example TNFis, biologics, and other agents for trial and exclusion considerations and provides context for preferred drug/product lists.
Objective measuresDisease-specific validated scores or laboratory/imaging markers (examples provided per indication in policy)
SCSubcutaneous route of administration
IVIntravenous route of administration
JIA / PJIA
Revision History
11/01/2024addedLatest
New policy created on 11/01/2024.
05/01/2025revised
Atopic Dermatitis: Added Ebglyss (lebrikizumab-lbkz) and Nemluvio (nemolizumab-ilto) as examples of systemic therapies and as examples of biologic immunomodulators not allowed concurrently with Rinvoq.
06/01/2025revised
Removed COVID-19 from Conditions Not Covered and added Giant Cell Arteritis indication.
Policy Summary
PayerCigna
PolicyRinvoq/Rinvoq LQ Prior Authorization Policy
Policy CodePolicy IP0682
Change TypeRevisions including added GCA indication and updated corticosteroid requirement
Effective DateJul 15, 2025
Next Review Date
Key ActionPrior Authorization is required for benefit coverage of Rinvoq/Rinvoq LQ; approvals provided for specified durations and prescriber specialty requirements must be met.
On This Page
1. Ankylosing Spondylitis (AS) - Rinvoq extended-release tablets only
A) Initial Therapy
Patient is ≥ 18 years of age
TNFi trial
Patient has had a 3-month trial of at least ONE tumor necrosis factor inhibitor
Conventional synthetic DMARDs do not count.
Patient tried at least one TNFi but was unable to tolerate a 3-month trial
Medication prescribed by or in consultation with a rheumatologist
B) Currently Receiving Rinvoq
Patient established on therapy for at least 6 months
Patients with <6 months or restarting are reviewed under Initial Therapy
ANY of the following
When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline
Examples of objective measures listed in policy
Patient experienced an improvement in at least one symptom (e.g., decreased pain or stiffness, improvement in function/ADLs)
2. Atopic Dermatitis (AD) - Rinvoq extended-release tablets only
A) Initial Therapy
Patient is ≥ 12 years of age
Systemic therapy trial
Patient has had a 4-month trial of at least ONE systemic therapy
Patient tried at least ONE systemic therapy but was unable to tolerate a 4-month trial
Medication prescribed by or in consultation with an allergist, immunologist, or dermatologist
B) Currently Receiving Rinvoq
3. Crohn's Disease (CD) - Rinvoq extended-release tablets only
A) Initial Therapy
Patient is ≥ 18 years of age
TNFi trial
Patient has had a 3-month trial of at least ONE tumor necrosis factor inhibitor
Patient tried at least one tumor necrosis factor inhibitor but was unable to tolerate a 3-month trial
Medication prescribed by or in consultation with a gastroenterologist
B) Currently Receiving Rinvoq
4. Giant Cell Arteritis (GCA) - Rinvoq extended-release tablets only
A) Initial Therapy
Patient is > 18 years of age
Patient has tried or is currently taking a systemic corticosteroid, or systemic corticosteroids are contraindicated
Medication prescribed by or in consultation with a rheumatologist
B) Patient is Currently Receiving Rinvoq extended-release tablets
Patient has been established on therapy for at least 6 months
C-reactive protein (CRP) elevated beyond the upper limit of normal for the reporting laboratory
Sacroiliitis reported on magnetic resonance imaging (MRI)
TNFi trial
Patient has had a 3-month trial of at least one tumor necrosis factor inhibitor
Patient experienced an improvement in at least one symptom (e.g., decreased pain or stiffness, improvement in function/ADLs)
2. Atopic Dermatitis - Continuation
B) Currently Receiving: Patient has been established on therapy for at least 90 days
Patients with <90 days or restarting are reviewed under Initial Therapy
Patient experienced a beneficial clinical response defined as improvement in at least one objective measure (estimated BSA affected, erythema, induration/papulation/edema, excoriations, lichenification, and/or decreased requirement for other therapies)
Compared with baseline, patient experienced an improvement in at least one symptom (e.g., decreased itching)
3. Crohn's Disease - Continuation
B) Currently Receiving: Patient established on therapy for at least 6 months
B) Currently Receiving: Patient has been established on the requested drug for at least 6 months
Response evidence
When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (examples: ASDAS, BASDAI, BASFI, serum markers)
Compared with baseline, patient experienced improvement in at least one symptom (e.g., decreased pain or stiffness, improved function/ADLs)
7. Psoriatic Arthritis - Continuation
B) Currently Receiving: Patient has been established on therapy for at least 6 months
Response evidence
When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (examples: DAPSA, CPDAI, PsA DAS, LEI, SPARCC, PsAID-12, CRP/ESR)
Compared with baseline, patient experienced improvement in at least one symptom (e.g., less joint pain, morning stiffness, fatigue, improved function)
8. Rheumatoid Arthritis - Continuation
B) Currently Receiving: Patient has been established on therapy for at least 6 months
Response evidence
Patient experienced a beneficial clinical response when assessed by at least one objective measure (examples: CDAI, DAS28-ESR/CRP, PAS-II, RAPID-3, SDAI)
Patient experienced improvement in at least one symptom (e.g., decreased joint pain, morning stiffness, fatigue)
9. Ulcerative Colitis - Continuation
B) Currently Receiving: Patient has been established on therapy for at least 6 months
Response evidence
When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (examples: fecal calprotectin, CRP, endoscopic assessment, reduced corticosteroid dose)
Compared with baseline, patient experienced improvement in at least one symptom (e.g., decreased pain, fatigue, stool frequency, rectal bleeding)
Concurrent use with other potent immunosuppressants (e.g., azathioprine, cyclosporine) is considered not medically necessary and may be denied
This does not exclude use with conventional synthetic DMARDs such as methotrexate
Billing Rule
Sample product not acceptable for coverage
Receipt of sample product does not satisfy any criteria requirements for coverage.
Denial Risk
Not medically necessary for non-listed uses or prohibited combinations
Use of Rinvoq/Rinvoq LQ for non-FDA-approved indications or concurrent use with other JAK inhibitors, biologics, or potent immunosuppressants (listed examples) is considered not medically necessary and may be denied.
Examples of potent immunosuppressants: azathioprine, cyclosporine
Concurrent use with other JAKis or biologic immunomodulators is not recommended
Documentation Required
Prescriber specialty requirement
Initial approvals require the medication to be prescribed by or in consultation with a specialist appropriate to the indication.
Examples of required prescriber specialties: rheumatologist, dermatologist, gastroenterologist, allergist/immunologist
AS / nr-axSpA / CD / UC / PsA / RAAS = Ankylosing spondylitis; nr-axSpA = Non-radiographic axial spondyloarthritis; CD = Crohn's disease; UC = Ulcerative colitis; PsA = Psoriatic arthritis; RA = Rheumatoid arthritis
07/15/2025revised
Giant Cell Arteritis: Changed requirement to 'tried or currently be taking a systemic corticosteroid, unless systemic corticosteroids are contraindicated.'
Patient established on therapy for at least 90 days
Patients with <90 days or restarting are reviewed under Initial Therapy
Patient experienced a beneficial clinical response defined as improvement in at least one objective measure (estimated BSA, erythema, induration/papulation/edema, excoriations, lichenification, and/or decreased requirement for other therapies)
Compared with baseline, patient experienced improvement in at least one symptom (e.g., decreased itching)
Patient established on therapy for at least 6 months
Patients with <6 months or restarting are reviewed under Initial Therapy