CurrentCignaPolicy IP0682

Rinvoq/Rinvoq LQ Prior Authorization Policy

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.

SourceLink

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)

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Typical initial approval months for most indications

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
  Examples: ASDAS, BASDAI, BASFI, BAS-G, BASMI, DFI, HAQ-S, serum markers (CRP, ESR)

Not Medically Necessary / Prohibited Combinations

General Dosing/Utilization Notes

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)
Prohibition: concurrent potent immunosuppressants: Concurrent use with other potent immunosuppressants (e.g., azathioprine, cyclosporine) is considered not medically necessary and may be denied

Applicable Codes & Appendix Drugs

Policy Identifiersmixed

IP0682

Coverage Policy Number

Drugs listed in appendixmixed

Otezla (apremilast)	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.

Affected code: IP0682
Prescriber specialties required: depends on indication (examples: rheumatologist, dermatologist, gastroenterologist, allergist/immunologist)

Documentation Required

Document trial and response

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.

Key definitions (operational)

TNFiTumor necrosis factor inhibitor (examples listed in Appendix: adalimumab, certolizumab, etanercept, infliximab, golimumab, etc.)

Objective measuresDisease-specific validated scores or laboratory/imaging markers (examples provided per indication in policy)

SCSubcutaneous route of administration

IVIntravenous route of administration

JIA / PJIAJIA = Juvenile idiopathic arthritis; PJIA = Polyarticular juvenile idiopathic arthritis

Revision History

11/01/2024addedLatest

New policy created on 11/01/2024.

05/01/2025revised

06/01/2025revised

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.

SourceLink

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
- ANY of the following

5. Juvenile Idiopathic Arthritis (JIA) - Rinvoq extended-release tablets or Rinvoq LQ oral solution

A) Initial Therapy
- Patient is ≥ 2 years of age
- Objective signs of inflammation
  - 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
Response evidence
- Beneficial clinical response by objective measure (e.g., fecal markers, serum markers, imaging, endoscopy, reduced steroid dose)
- Improvement in at least one symptom (e.g., decreased pain, fatigue, stool frequency, blood in stool)

4. Giant Cell Arteritis - Continuation

B) Currently Receiving: Patient has been established on therapy for at least 6 months
Response evidence
- Beneficial clinical response by objective measure (e.g., serum markers CRP/ESR, resolution of fever, reduced corticosteroid dose)
- Improvement in at least one symptom (e.g., decreased headache, scalp/jaw pain, decreased fatigue, improved vision)

5. Juvenile Idiopathic Arthritis - Continuation

B) Currently Receiving: Patient has been established on therapy for at least 6 months
Response evidence
- Beneficial clinical response by objective measure (examples: MD global, PGA, PDA, JADAS, cJADAS, JSpADA, CRP/ESR, reduced corticosteroid dose)
- Improvement in at least one symptom (e.g., decreased pain/stiffness, improved function/ADLs)

6. Non-Radiographic Axial Spondyloarthritis - Continuation

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)

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

Removed COVID-19 from Conditions Not Covered and added Giant Cell Arteritis indication.

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

ANY of the following

Beneficial clinical response by objective measure (e.g., fecal markers, serum markers, imaging, endoscopy, reduced steroid dose)
Improvement in at least one symptom (e.g., decreased pain, fatigue, stool frequency, blood in stool)

Beneficial clinical response by objective measure (e.g., serum markers, resolution of fever, reduced corticosteroid dose)

Improvement in at least one symptom (e.g., decreased headache, scalp/jaw pain, fatigue, improved vision)

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 rheumatologist

B) Currently Receiving Rinvoq/Rinvoq LQ

Patient has been established on therapy for at least 6 months
Patients with <6 months or restarting are reviewed under Initial Therapy
ANY of the following
- Beneficial clinical response by objective measure (examples: MD global, PGA, PDA, JADAS, cJADAS, JSpADA, CRP/ESR, reduced corticosteroid dose)
- Improvement in at least one symptom (e.g., decreased pain/stiffness, improved function/ADLs)