CurrentColorado Rocky Mountain Health PlansPolicy N/A

Rinvoq (upadacitinib) / Rinvoq LQ prior authorization / medical necessity

Prior authorization and medical necessity criteria for Rinvoq (upadacitinib) extended-release tablets and Rinvoq LQ oral solution across multiple FDA-approved indications (RA, PsA, atopic dermatitis, UC, Crohn's disease, ankylosing spondylitis, non-radiographic axial spondyloarthritis, pJIA, polyarticular JIA, giant cell arteritis). Includes initial and reauthorization requirements, prescribing specialties, combination therapy exclusions, and documentation rules.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRinvoq (upadacitinib) / Rinvoq LQ prior authorization / medical necessity

Policy CodePolicy N/A

Change TypeCriteria update (added GCA)

Effective DateFeb 1, 2026

Next Review Date

Key ActionRinvoq/Rinvoq LQ requires prior authorization; initial and reauthorization criteria must be documented (diagnosis, trials, dates, duration, claims or medical records).

SourceLink

POLICY UPDATE CHANGES

Added Giant Cell Arteritis (GCA) coverage criteria (6/2025 and 7/2025 entries reflect addition).

12Covered Indications (listed)

12 moTypical authorization duration

MultiplePrescribing specialties required

Coverage Summary

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.

This policy defines prior authorization and medical necessity criteria for Rinvoq (upadacitinib) extended‑release tablets and Rinvoq LQ oral solution across the listed FDA indications including rheumatoid arthritis (RA), psoriatic arthritis (PsA), atopic dermatitis, ulcerative colitis (UC), Crohn's disease, ankylosing spondylitis, non‑radiographic axial spondyloarthritis, polyarticular juvenile idiopathic arthritis (pJIA)/polyarticular JIA, and giant cell arteritis (GCA).

Coverage is covered_with_criteria: approval requires meeting indication‑specific initial authorization or reauthorization criteria (diagnosis, prior therapy trials or documented established use, prescriber specialty or consultation, and other documentation).

Authorizations for most indications are issued for 12 months. Many indications require specialist prescribing or consultation (e.g., rheumatologist, dermatologist, gastroenterologist, allergist/immunologist, depending on indication).

Quick thresholds and facts

DMARD trial duration (RA)3 months trial of one non-biologic DMARD at maximally indicated dose (unless contraindicated or intolerant)

Methotrexate trial duration (PsA)3 months trial of methotrexate at maximally indicated dose (unless contraindicated or intolerant)

NSAID trial requirement (AS/axial SpA)Failure to two NSAIDs at maximally indicated doses, each used for at least 4 weeks (unless contraindicated)

Topical therapy requirement (Atopic Dermatitis)Failure, contraindication, or intolerance to two topical therapy classes (medium–very high potency topical corticosteroid; topical calcineurin inhibitor; Eucrisa/crisaborole)

Systemic atopic dermatitis trial durationSubmission of medical records documenting a 3 month trial of a systemic drug product for atopic dermatitis (or physician attestation that systemic therapies are inadvisable)

Authorization durationAuthorizations will be issued for 12 months for most indications

Initial Therapy Criteria (by indication)

Rheumatoid Arthritis - Initial Authorization

ref

title

ref_value_missing_error_message

Psoriatic Arthritis (PsA) - Initial Authorization

ref

title

Atopic Dermatitis - Initial Authorization

ref

title

Ulcerative Colitis - Initial Authorization

ref

title

Ankylosing Spondylitis / Non-radiographic Axial Spondyloarthritis - Initial Authorization

ref

title

Crohn's Disease - Initial Authorization

ref

title

Polyarticular Juvenile Idiopathic Arthritis (pJIA) / Polyarticular JIA - Initial Authorization

ref

title

Giant Cell Arteritis (GCA) - Initial Authorization

ref

title

Continuation / Reauthorization Criteria (by indication)

Rheumatoid Arthritis - Reauthorization

ref

title

Psoriatic Arthritis - Reauthorization

ref

title

Atopic Dermatitis - Reauthorization

ref

title

Ulcerative Colitis - Reauthorization

ref

title

Ankylosing Spondylitis / Non-radiographic Axial Spondyloarthritis - Reauthorization

ref

title

Crohn's Disease - Reauthorization

ref

title

pJIA / Polyarticular JIA - Reauthorization

ref

title

Giant Cell Arteritis - Reauthorization

ref

title

Exclusions, Prohibitions & Not Medically Necessary Rules

The policy explicitly prohibits co‑prescribing Rinvoq (or Rinvoq LQ) in combination with another systemic targeted immunomodulator or with a potent immunosuppressant for the same indication; such combination use disallows approval.

Examples of systemic targeted immunomodulators cited in the policy include agents such as adalimumab, certolizumab (Cimzia), etanercept (Enbrel), abatacept (Orencia), golimumab (Simponi), tofacitinib (Xeljanz/XR), bimekizumab (Bimzelx), secukinumab (Cosentyx), apremilast (Otezla), risankizumab (Skyrizi), ixekizumab (Taltz), guselkumab (Tremfya), vedolizumab (Entyvio), mirikizumab (Omvoh), ustekinumab, ozanimod (Zeposia), tralokinumab (Adbry), dupilumab (Dupixent), lebrikizumab (Ebglyss), nemolizumab (Nemluvio), baricitinib (Olumiant), abrocitinib (Cibinqo), and topical ruxolitinib (Opzelura) as applicable examples.

Examples of potent immunosuppressants given include azathioprine, cyclosporine, mycophenolate mofetil, and 6‑mercaptopurine. Claims and medical records will be reviewed and combination therapy is grounds for denial of authorization.

Examples of systemic targeted immunomodulators (mentioned as exclusions or prior therapies)mixed

	adalimumab (example)
	certolizumab (Cimzia)
	etanercept (Enbrel)
	abatacept (Orencia)
	golimumab (Simponi)
	tofacitinib (Xeljanz/XR)
	bimekizumab (Bimzelx)
	secukinumab (Cosentyx)
	apremilast (Otezla)
	risankizumab (Skyrizi)

1–10 of 23

1/3

Examples of potent immunosuppressants (exclusion examples)mixed

	azathioprine
	cyclosporine
	mycophenolate mofetil
	6-mercaptopurine

Topical therapies referenced for atopic dermatitismixed

	medium to very-high potency topical corticosteroids (examples listed in Table 1)
	topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus)
	crisaborole (Eucrisa)

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Rinvoq/Rinvoq LQ requires prior authorization; initial and reauthorization criteria must be documented (diagnosis, trials, dates, duration, claims or medical records).

Documentation Required

Document prior therapy trials

Document drug name, dates, and duration of trials for prior non-biologic DMARDs, TNF inhibitors, systemic therapies, topical therapies, or biologics as applicable to the indication; claims history may substitute when specified.

Documentation Required

Needle-phobia documentation

If relying on a needle‑phobia exception, document the condition per DSM‑V‑TR 300.29 and that the patient previously refused injectable therapy or a medical procedure.

Step Therapy

Step therapy / failure requirements

Many indications require failure or intolerance to specified drug classes (e.g., non‑biologic DMARDs, methotrexate, TNF inhibitors, systemic therapies, or NSAIDs) before approval; follow the indication‑specific step requirements and note state‑specific footnotes (e.g., 30‑day trial requirement for CT/KY/MS).

Billing Rule

Authorization duration

Authorizations for most indications will be issued for 12 months.

Documentation Required

Combination therapy prohibition

Do not co‑prescribe Rinvoq with another systemic targeted immunomodulator or a potent immunosuppressant for the same indication; such combination use disallows approval and claims will be reviewed.

Denial Risk

Manufacturer sample exclusion for established-user pathway

Manufacturer‑supplied free samples or assistance from the AbbVie Rinvoq Complete program cannot be used to establish current user for the established‑on‑therapy pathway; patients who were established via samples or program assistance must meet initial authorization criteria as if new to therapy.

Clinical Evidence, Background & Definitions

Rinvoq is an oral Janus kinase (JAK) inhibitor with multiple FDA‑approved indications across rheumatology, dermatology, and gastroenterology.

The policy provides indication‑specific prior authorization (initial and reauthorization) criteria including required prior therapy trials or documentation of current therapy, specialist prescriber requirements, and documentation rules (drug names, dates, durations, claims or medical records).

The policy enforces limits against combination therapy with other JAK inhibitors, biologic DMARDs, systemic targeted immunomodulators, or potent immunosuppressants, and it requires using the lowest effective dose to maintain response. For indications where applicable (per product labeling), Rinvoq should be discontinued if adequate therapeutic response is not achieved with the 30 mg dosage.

ACR 2021Guideline references: ACR 2021 (RA) + other specialty guidelines

Oct 2025Package insert date: Rinvoq package insert (AbbVie) Oct 2025

Needle‑phobia: Documented phobia meeting DSM‑V‑TR 300.29 criteria resulting in prior refusal of injectable therapy or medical procedure.

Established on therapy via manufacturer sample: Receipt of a manufacturer‑supplied free sample or AbbVie program assistance in the prescriber's office is not acceptable to establish current user for the initial‑authorize‑as‑established pathway; such patients must meet initial authorization criteria as if new to therapy.

Note: Documentation requirements for trials (drug, dates, duration) and claims or medical record submission are required to support prior therapy or established use.

Revision History

5/2020change_control

Program established / new prior authorization program for Rinvoq (upadacitinib).

5/2021change_control

Annual review; removed preceding month requirement from failure criteria and removed prescriber requirement from reauthorization; references updated.

6/2021change_control

Added coverage criteria for patients previously treated with a biologic DMARD and clarified documentation requirements to bypass non-biologic therapies when claims history is unavailable.

12/2021change_control

Updated conventional DMARD bypass language for rheumatoid arthritis and updated CT/KY footnote.

2/2022change_control

Added step through a TNF inhibitor for RA and added coverage criteria for psoriatic arthritis per updated label; background and references updated.

3/2022change_control

Added coverage criteria for new indication: atopic dermatitis; updated background and references.

5/2022change_control

Added coverage criteria for new indication: ulcerative colitis; updated state mandate to include Mississippi and updated references.

6/2022change_control

Updated background and added coverage criteria for new indication: ankylosing spondylitis.

7/2022change_control

Removed age requirement from initial authorization criteria for atopic dermatitis.

12/2022change_control

Added coverage criteria for new indication: non-radiographic axial spondyloarthritis; references updated.

7/2023change_control

Updated not-receiving-in-combination language to 'targeted immunomodulator' and updated examples; added coverage criteria for Crohn's disease; references updated.

9/2023change_control

Updated examples with no change to coverage criteria.

6/2024change_control

Added Rinvoq LQ to the program and updated criteria with pediatric PsA indication; added pJIA criteria; background, references and state mandate footnote updated.

4/2025change_control

Annual review; added Ebglyss as an example of systemic drug product and updated examples without change to clinical intent.

6/2025change_control

Updated background and added coverage criteria for new indication: Giant Cell Arteritis (GCA).

7/2025change_control

Added Nemluvio as a try/fail drug option for atopic dermatitis.

11/2025change_controlLatest

Updated criteria to reflect updated ulcerative colitis and Crohn's disease indications regarding TNF blockers; updated background, references, and combination therapy examples and language (no change to clinical intent).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRinvoq (upadacitinib) / Rinvoq LQ prior authorization / medical necessity

Policy CodePolicy N/A

Change TypeCriteria update (added GCA)

Effective DateFeb 1, 2026

Next Review Date

Key ActionRinvoq/Rinvoq LQ requires prior authorization; initial and reauthorization criteria must be documented (diagnosis, trials, dates, duration, claims or medical records).

SourceLink

On This Page