ModifiedCignaPolicy N/A

Inflammatory Conditions - Rinvoq/Rinvoq LQ Prior Authorization Policy

Defines prior authorization requirements and medical necessity criteria for coverage of Rinvoq (upadacitinib ER tablets) and Rinvoq LQ (oral solution) across multiple inflammatory indications for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyInflammatory Conditions - Rinvoq/Rinvoq LQ Prior Authorization Policy

Policy CodePolicy N/A

Change TypeMaterial revisions and indication additions

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of indication-specific age and a 3-month trial of at least one TNF inhibitor (or intolerance) and ensure medication is prescribed by or in consultation with the appropriate specialist.

SourceLink

POLICY UPDATE CHANGES

Policy name changed from 'Inflammatory Conditions - Rinvoq' to 'Inflammatory Conditions - Rinvoq/Rinvoq LQ' and for most indications specified that approval is for Rinvoq tablets (not Rinvoq LQ) except JIA and psoriatic arthritis.

Juvenile Idiopathic Arthritis was added as a newly approved indication with age requirements.

Conditions Not Covered: concurrent use with a biologic or targeted synthetic oral small molecule drug was updated and concurrent use with another JAK inhibitor was removed.

Giant Cell Arteritis was added as a newly approved indication.

For Giant Cell Arteritis the corticosteroid requirement changed to allow patients who tried or are currently taking a systemic corticosteroid unless contraindicated.

02/26/2025review date shown

multiple

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Indication-Specific Medical Necessity

Indication-specific medical necessity criteria (Initial and Continuation Therapy)

Covered when ALL of the following are met (per indication) — approvals differ for Initial Therapy vs Currently Receiving:

Indication selection

Ankylosing Spondylitis - Initial Therapy: Patient is ≥ 18 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial (conventional synthetic DMARDs do not count); AND medication is prescribed by or in consultation with a rheumatologist.Approve for 6 months
Rinvoq ER tablets only; see Appendix for TNF inhibitor examples.
Ankylosing Spondylitis - Currently Receiving: Patient has been established on Rinvoq extended‑release tablets for ≥ 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., decreased pain or stiffness, improved function).Approve for 1 year
Objective measure examples listed in policy (ASDAS, BASDAI, CRP, etc.).
Atopic Dermatitis - Initial Therapy: Patient is ≥ 12 years of age; AND patient has had a 4‑month trial of at least one systemic therapy OR tried at least one systemic therapy but was unable to tolerate a 4‑month trial; AND medication is prescribed by or in consultation with an allergist, immunologist, or dermatologist.Approve for 3 months
Rinvoq ER tablets only; examples of systemic therapies provided in policy.
Atopic Dermatitis - Currently Receiving: Patient has been established on Rinvoq extended‑release tablets for ≥ 90 days; AND experienced a beneficial clinical response (improvement in measures such as BSA affected, erythema, induration/papulation/edema, excoriations, lichenification, or decreased need for other AD therapies); AND improvement in at least one symptom (e.g., decreased itching).Approve for 1 year
Examples of clinical response provided in policy.
Crohn's Disease - Initial Therapy: Patient is ≥ 18 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial; AND medication is prescribed by or in consultation with a gastroenterologist.Approve for 6 months
Rinvoq ER tablets only; objective measures examples include fecal markers, CRP, imaging, endoscopy, steroid dose.
Crohn's Disease - Currently Receiving: Patient has been established on Rinvoq extended‑release tablets for ≥ 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., decreased pain, fatigue, stool frequency, or blood in stool).Approve for 1 year
Objective measures examples listed in policy.
Giant Cell Arteritis - Initial Therapy: Patient is > 18 years of age; AND patient has tried or is currently taking a systemic corticosteroid (or systemic corticosteroids are contraindicated); AND medication is prescribed by or in consultation with a rheumatologist.Approve for 6 months
Rinvoq ER tablets only; corticosteroid example: prednisone.
Giant Cell Arteritis - Currently Receiving: Patient has been established on Rinvoq extended‑release tablets for ≥ 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., decreased headache, scalp or jaw pain, fatigue, improved vision).Approve for 1 year
Objective measures include CRP, ESR, resolution of fever, reduced corticosteroid dose.
Juvenile Idiopathic Arthritis - Initial Therapy: Patient is ≥ 2 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial (conventional synthetic DMARDs do not count); AND medication is prescribed by or in consultation with a rheumatologist.Approve for 6 months
Rinvoq ER tablets or Rinvoq LQ permitted per age/indication; see Appendix for TNF inhibitor examples.
Juvenile Idiopathic Arthritis - Currently Receiving: Patient has been established on Rinvoq or Rinvoq LQ for ≥ 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., decreased joint pain, less morning stiffness, improved function).Approve for 1 year
Objective measures include Physician Global, PGA, JADAS, cJADAS, JSpADA, CRP/ESR.
Non‑Radiographic Axial Spondyloarthritis - Initial Therapy: Patient is ≥ 18 years of age; AND patient has objective signs of inflammation (CRP elevated above lab ULN OR sacroiliitis on MRI); AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial; AND medication is prescribed by or in consultation with a rheumatologist.Approve for 6 months
Approval limited to Rinvoq extended‑release tablets (not Rinvoq LQ).
Non‑Radiographic Axial Spondyloarthritis - Currently Receiving: Patient has been established on Rinvoq extended‑release tablets for ≥ 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., decreased pain or stiffness, improved function).Approve for 1 year
Objective measure examples include ASDAS, BASDAI, CRP, MRI.
Psoriatic Arthritis - Initial Therapy: Patient is ≥ 2 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial; AND medication is prescribed by or in consultation with a rheumatologist or dermatologist.Approve for 6 months
Rinvoq ER tablets or Rinvoq LQ permitted per age/indication; conventional synthetic DMARDs do not count.
Psoriatic Arthritis - Currently Receiving: Patient has been established on Rinvoq or Rinvoq LQ for ≥ 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., less joint pain, morning stiffness, improved function).Approve for 1 year
Objective measures examples include DAPSA, CPDAI, PsA DAS, LEI, MDA, PsAID‑12, CRP/ESR.
Rheumatoid Arthritis - Initial Therapy: Patient is ≥ 18 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial; AND medication is prescribed by or in consultation with a rheumatologist.Approve for 6 months
Approval limited to Rinvoq extended‑release tablets (not Rinvoq LQ); conventional synthetic DMARDs do not count.
Rheumatoid Arthritis - Currently Receiving: Patient has been established on Rinvoq extended‑release tablets for ≥ 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., decreased joint pain, morning stiffness, improved function).Approve for 1 year
Objective measures examples include CDAI, DAS28‑ESR/CRP, RAPID‑3, SDAI.
Ulcerative Colitis - Initial Therapy: Patient is ≥ 18 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial; AND medication is prescribed by or in consultation with a gastroenterologist.Approve for 6 months
Approval limited to Rinvoq extended‑release tablets (not Rinvoq LQ); objective measures include fecal markers, CRP, endoscopic assessment, and corticosteroid dose reduction.
Ulcerative Colitis - Currently Receiving: Patient has been established on Rinvoq extended‑release tablets for ≥ 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., reduced stool frequency, less rectal bleeding).Approve for 1 year
Objective measures examples include fecal calprotectin and endoscopy.

Juvenile Idiopathic Arthritis - Initial Therapy

Approve for JIA when the following criteria are met:

Initial Therapy (approve 6 months): Patient is ≥ 2 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial (conventional synthetic DMARDs do not count); AND medication is prescribed by or in consultation with a rheumatologist.age ≥ 2 years; 3‑month TNF trial

Conventional synthetic DMARDs do not count; see Appendix for TNF inhibitor examples.

Juvenile Idiopathic Arthritis - Continuation Therapy

Approve for 1 year for patients currently receiving Rinvoq/Rinvoq LQ when ALL of the following are met:

Continuation Therapy (approve 1 year): Patient has been established on therapy for at least 6 months; AND patient meets at least ONE of: (a) when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR (b) improvement in at least one symptom (e.g., decreased joint pain, less morning stiffness, improved function).established ≥ 6 months

Patients with <6 months or restarting are reviewed under Initial Therapy criteria.

Non-Radiographic Axial Spondyloarthritis - Initial/Continuation criteria (tablets only)

Approve Rinvoq extended‑release tablets (not Rinvoq LQ) for nr‑axSpA when these criteria apply:

Initial Therapy (approve 6 months): Patient is ≥ 18 years of age; AND patient has objective signs of inflammation defined as at least ONE of: elevated CRP above the reporting laboratory upper limit of normal OR sacroiliitis on MRI; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial; AND medication is prescribed by or in consultation with a rheumatologist.age ≥ 18; objective inflammation; 3‑month TNF trial

Approval limited to Rinvoq extended‑release tablets (not Rinvoq LQ).

Continuation Therapy (approve 1 year): Patient has been established on the requested drug for at least 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom compared with baseline.established ≥ 6 months

Examples of objective measures provided (ASDAS, BASDAI, CRP, MRI).

Psoriatic Arthritis - criteria (tablets or LQ where applicable)

Approve Rinvoq (tablets or LQ) for Psoriatic Arthritis when criteria are met:

Initial Therapy (approve 6 months): Patient is ≥ 2 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial; AND medication is prescribed by or in consultation with a rheumatologist or dermatologist.age ≥ 2; 3‑month TNF trial

Conventional synthetic DMARDs do not count; appendix lists TNF inhibitor examples.

Continuation Therapy (approve 1 year): Patient has been established on Rinvoq or Rinvoq LQ for at least 6 months; AND patient meets at least ONE of: (a) when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR (b) improvement in at least one symptom compared with baseline (e.g., less joint pain, morning stiffness, improved function).established ≥ 6 months

Objective measures examples include DAPSA, CPDAI, PsA DAS, LEI, MDA, PsAID‑12, CRP/ESR.

Rheumatoid Arthritis - criteria (tablets only)

Approve Rinvoq extended‑release tablets for Rheumatoid Arthritis when criteria are met:

Initial Therapy (approve 6 months): Patient is ≥ 18 years of age; AND patient has had a 3‑month trial of at least one tumor necrosis factor inhibitor OR tried at least one TNF inhibitor but was unable to tolerate a 3‑month trial; AND medication is prescribed by or in consultation with a rheumatologist.age ≥ 18; 3‑month TNF trial

Conventional synthetic DMARDs do not count; approval limited to Rinvoq extended‑release tablets (not Rinvoq LQ).

Continuation Therapy (approve 1 year): Patient has been established on Rinvoq extended‑release tablets for at least 6 months; AND patient experienced a beneficial clinical response when assessed by at least one objective measure OR experienced improvement in at least one symptom compared with baseline.established ≥ 6 months

Objective measures examples include CDAI, DAS28‑ESR/CRP, RAPID‑3, SDAI.

Ulcerative Colitis - criteria (tablets only)

Approve Rinvoq extended‑release tablets for Ulcerative Colitis when criteria are met:

Approval limited to Rinvoq extended‑release tablets (not Rinvoq LQ); objective measures include fecal markers, CRP, endoscopic assessment, and corticosteroid dose reduction.

Continuation Therapy (approve 1 year): Patient has been established on Rinvoq extended‑release tablets for at least 6 months; AND when assessed by at least one objective measure experienced a beneficial clinical response from baseline OR experienced improvement in at least one symptom (e.g., reduced stool frequency, decreased rectal bleeding).established ≥ 6 months

Objective measures examples include fecal calprotectin and endoscopy.

Rinvoq and Rinvoq LQ should not be used in combination with other therapies that increase immunosuppression. Specifically, for all indications the policy states that these agents are not recommended for concomitant use with other Janus kinase inhibitors, biologic therapies, or potent immunosuppressants (for example, azathioprine or cyclosporine).

Concurrent administration of Rinvoq or Rinvoq LQ with another biologic or with a targeted synthetic oral small molecule used for inflammatory conditions is considered not medically necessary. The policy explains that combination therapy is generally not recommended because of a potentially higher rate of adverse events and lack of controlled data demonstrating additive benefit, and it also specifies that co-administration with other potent immunosuppressants (e.g., azathioprine, cyclosporine) is not covered.

The appendix provides examples of biologic and targeted therapies but is explicitly noted as not an all-inclusive list. Providers should refer to each agent's prescribing information for FDA‑approved indications; the appendix is for reference only and does not replace the product labeling.

Use of Rinvoq or Rinvoq LQ for indications not listed among the FDA‑approved indications in this policy segment is considered not medically necessary. Requests for off‑label uses or combinations with other biologic or targeted agents may be denied per the policy.

There are no specific not‑medically‑necessary (NMN) determinations listed in the appendix pages beyond the general statements above; the appendix instead lists agents and indications for reference and reiterates that the list is not exhaustive.

Coding and Therapy Parameters

Listed productsmixed

Rinvoq	upadacitinib extended-release tablets (product name listed in Appendix)
Rinvoq LQ	upadacitinib oral solution (product name listed in Appendix)

No CPT/HCPCS/ICD-10/NDC codes listedmixed

No codes listed

Prior TNF inhibitor trial — inv-15: key facts

Requirement3-month trial of at least one tumor necrosis factor inhibitor, or inability to tolerate a 3-month trial

Applies toInitial therapy criteria for multiple indications (e.g., JIA, PsA, RA, UC, nr-axSpA, Crohn's disease)

ExclusionsConventional synthetic DMARDs (e.g., methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) do not count toward the TNFi requirement

Initial approval duration — inv-16

Typical initial approval length6 months

Applies toInitial Therapy across multiple indications (see indication-specific criteria)

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Rinvoq/Rinvoq LQ prescription benefit coverage requires prior authorization. Initial approvals require the prescriber to be a specialist in the treated condition or involve consultation with that specialist. Approvals are issued for the durations noted in the policy; where duration is expressed in months, 1 month = 30 days.

Prior authorization is required for prescription benefit coverage of Rinvoq and Rinvoq LQ.
Initial approval generally requires the medication to be prescribed by or in consultation with a specialist (e.g., rheumatologist, gastroenterologist, dermatologist) depending on the indication.
Approval durations: Initial therapy approvals typically 6 months; patients currently receiving therapy typically approved for 1 year; established therapy generally defined as ≥ 6 months (see indication-specific criteria).

Step Therapy

TNF Inhibitor Step Requirement

TNF inhibitor step therapy is required for many indications. For initial therapy, the patient must have documentation of a 3-month trial of at least one tumor necrosis factor (TNFi) inhibitor or documented intolerance to such a trial. This requirement applies across multiple FDA-approved indications (see policy sections for specific age/indication details).

Definitions and Abbreviations

Rinvoq LQ substitutability — inv-32

SubstitutabilityRinvoq LQ oral solution is not substitutable with Rinvoq extended‑release tablets

Restricted indications for LQRinvoq LQ is indicated only for polyarticular juvenile idiopathic arthritis and psoriatic arthritis in patients 2 to <18 years

Formulation noteFor most indications approval is limited to Rinvoq extended‑release tablets (Rinvoq LQ limited to specified pediatric indications)

Combination therapy restriction — inv-33

Combination use policyRinvoq/Rinvoq LQ is not recommended for use in combination with other JAK inhibitors, biologics, or potent immunosuppressants (e.g., azathioprine, cyclosporine)

Coverage implicationConcurrent use with a biologic or targeted synthetic oral small molecule drug may be considered not medically necessary and denied

Background

Rinvoq (upadacitinib) is an oral Janus kinase (JAK) inhibitor indicated across multiple inflammatory conditions, including ankylosing spondylitis, atopic dermatitis, Crohn's disease, giant cell arteritis, non‑radiographic axial spondyloarthritis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis. The policy also notes that Rinvoq LQ (oral solution) is a distinct formulation with more limited pediatric indications (polyarticular JIA and psoriatic arthritis in patients 2 to <18 years) and is not substitutable with the extended‑release tablets.

Revision History and Policy Changes

05/15/2024selected_revision

Policy updated to specify age requirements for nr-axSpA (≥18) and JIA (≥2); concurrent use language changed (concurrent use with another JAK inhibitor removed) and Rinvoq LQ use limited (Rinvoq tablets specified for most indications except JIA and PsA); JIA added as a newly approved indication and PsA expanded to age ≥2.

09/11/2024selected_revision

Clarified Conditions Not Covered language and removed concurrent use with another Janus kinase inhibitor; non-radiographic axial spondyloarthritis initial approval age requirement reinforced.

02/26/2025

Policy Summary

PayerCigna

PolicyInflammatory Conditions - Rinvoq/Rinvoq LQ Prior Authorization Policy

Policy CodePolicy N/A

Change TypeMaterial revisions and indication additions

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

A 3-month trial of at least one TNF inhibitor is required for initial approval for numerous indications (e.g., ankylosing spondylitis, Crohn's disease, psoriatic arthritis, rheumatoid arthritis, ulcerative colitis, juvenile indications where applicable).
If the patient could not tolerate a 3-month TNFi trial, document the intolerance or incomplete trial.
Refer to the Appendix for examples of TNF inhibitors; conventional synthetic DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) do not satisfy the TNFi trial requirement.

Documentation Required

Prior Authorization and Approval Durations; Required Documentation

Required clinical documentation and approval durations differ for initial versus continuation therapy. Initial approvals usually require age, prior treatment trials (including TNFi), specialist prescriber or consultation, and objective measures where noted. Continuation approvals require documentation of established therapy (typically ≥ 6 months) and evidence of benefit (objective measures or symptom improvement).

Initial therapy documentation: patient age, evidence of prior TNFi trial or intolerance, specialist prescriber/consultation, indication-specific objective measures if required.
Continuation therapy documentation: established on drug ≥ 6 months and evidence of clinical benefit by objective measure or symptom improvement (examples vary by indication — e.g., CRP, imaging, disease activity scores, fecal markers).
Approval durations: Initial — typically 6 months; Continuation (currently receiving) — typically 1 year.

Note

Agent List — Appendix Informational Only

Appendix lists agents (biologics, targeted therapies, oral small molecules, examples of TNF inhibitors) for reference but does not itself impose prior authorization rules or step therapy exceptions. The appendix is informational and includes examples of agents; prescribers should refer to the policy criteria for required trials and exclusions.

Appendix provides examples of biologic agents, oral targeted therapies, JAK inhibitors, TNF inhibitors, and other immunomodulators.
Appendix does NOT specify prior authorization or step-therapy rules — those are described in the main policy criteria.
Use the Appendix only as examples for identifying prior biologic or targeted therapies; it does not substitute for documented trial information required for authorization.

Denial Risk

Coding / Claim Denial Risk

Claims without covered diagnosis or procedure codes consistent with the policy criteria will be denied. When billing, providers must use the most appropriate codes as of the submission date; services billed for diagnoses not covered by the policy will be denied as not covered.

Ensure submitted claims include covered diagnosis/procedure codes consistent with the applicable coverage criteria.
Claims submitted without covered codes under this policy will be denied as not covered.
Verify coding aligns with the member's benefit plan and the effective date of service.

Denial Risk

Conditions Not Covered — Concurrent Therapy

Conditions Not Covered — Concurrent use of Rinvoq or Rinvoq LQ with certain therapies is considered not medically necessary and will not be approved. Specifically, combination therapy with other biologics, targeted synthetic oral small molecules, biologic immunomodulators, or other potent immunosuppressants is not allowed (exceptions noted in policy).

Concurrent use with another biologic or a targeted synthetic oral small molecule drug for inflammatory conditions is not medically necessary.
Concurrent use with biologic immunomodulators is not recommended.
Concurrent use with other potent immunosuppressants (e.g., azathioprine, cyclosporine) is not allowed; this does not exclude use with conventional synthetic DMARDs such as methotrexate.
Refer to the policy Appendix for examples of biologics, immunomodulators, and oral targeted therapies.

Note

Provider Actions — Appendix Pages

No specific provider actions or additional authorization triggers are specified on the Appendix pages. The Appendix serves as a reference list only; follow the main policy criteria for authorization triggers and required documentation.

Appendix pages do not include separate provider action steps or authorization triggers.
Providers should follow the main policy sections for required trials, documentation, and prescriber specialty requirements.

Objective measures — inv-34

Examples of objective measuresDisease‑specific validated scores (e.g., ASDAS, BASDAI, DAPSA, CDAI, DAS28, JADAS/cJADAS/JSpADA), serum markers (CRP, ESR), fecal calprotectin, endoscopic assessment, MRI evidence (sacroiliitis)

Use caseRequired to document beneficial clinical response for continuation (patient established ≥6 months)

Symptom improvementsImprovement in at least one symptom (e.g., decreased joint pain, less morning stiffness, reduced stool frequency/rectal bleeding) may also satisfy continuation criteria