CurrentMass General Brigham Health PlanPolicy N/A

Rinvoq (upadacitinib) Rinvoq LQ (updacitinib) Effective 07/01/2025 MassHealth UPPL

Prior authorization, quantity limits, step therapy and specialty pharmacy requirements for Rinvoq (upadacitinib) tablets and Rinvoq LQ oral solution across Mass General Brigham Health Plan (MassHealth UPPL), covering multiple FDA-indications with diagnosis-specific authorization criteria, continuation (reauthorization) rules, and product-specific limitations.

Policy Summary

PayerMass General Brigham Health Plan

PolicyRinvoq (upadacitinib) Rinvoq LQ (updacitinib) Effective 07/01/2025 MassHealth UPPL

Policy CodePolicy N/A

Change TypeAdded product; revised indication criteria and reauthorization rules

Effective DateJul 1, 2025

Next Review Date

Key ActionPrior authorization is required for Rinvoq and Rinvoq LQ; submit documentation of prior therapy trials, durations, and failures and fill at a contracted specialty pharmacy as applicable.

SourceLink

POLICY UPDATE CHANGES

Added Rinvoq LQ to the policy and added criteria for pJIA; Rinvoq LQ only approved for psoriatic arthritis and pJIA.

Updated atopic dermatitis criteria to include Ebglyss as a systemic single step option and to require prior trial of Adbry or Dupixent (history of changes culminating 04/01/2025 and 07/01/2025 effective).

Updated Crohn's disease and ulcerative colitis criteria to remove disease characteristic requirement and allow approval if disease severity warrants systemic biologic as first-line therapy.

Updated nr-axSpA criteria to require trial and failure with minimum 1 month and two NSAIDs (effective 01/01/2025).

Updated approval lengths and reauthorization criteria for atopic dermatitis (initial approvals 6 months; reauthorizations 12 months).

8FDA Indications Covered (listed)

1/dayTablet daily limit

12 mL/dayRinvoq LQ solution daily limit

90 daysNew-member continuation window

Coverage Summary & Gateway

This policy requires prior authorization for Rinvoq tablets and Rinvoq LQ oral solution, applies specialty pharmacy fill requirements, enforces quantity limits of 1 tablet per day for Rinvoq tablets and 12 mL per day for Rinvoq LQ, and implements diagnosis-specific step therapy and documentation requirements aligned to FDA indications; product-specific limitations restrict Rinvoq LQ to certain indications.

Initial Therapy Criteria (by indication)

Continuation Therapy / Reauthorization

Per the March/April 2025 updates, initial approvals for atopic dermatitis are granted for 6 months with reauthorizations for AD granted for 12 months; other diagnoses (including Rinvoq LQ–eligible indications) have initial and reauthorization approvals granted for 24 months per the April 2025 review and associated effective dates.

Product-Specific Restrictions & Exclusions

Rinvoq LQ will only be approved for the treatment of psoriatic arthritis and polyarticular juvenile idiopathic arthritis (pJIA); prior updates (09/11/2024, 10/09/2024 and subsequent notes) added Rinvoq LQ to the policy and established this product-specific restriction. Providers must follow prior authorization requirements, document required trials and failures (including TNF blockers) per the indication-specific criteria, and submit reauthorization evidence of clinical improvement when applicable. Rinvoq and Rinvoq LQ are not recommended in combination with other JAK inhibitors, biologic DMARDs, or potent immunosuppressants.

Provider Actions & Operational Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for both Rinvoq (upadacitinib) tablets and Rinvoq LQ (oral solution). These products are designated specialty and must be filled at a contracted specialty pharmacy. Authorization may be granted for members new to the plan within the past 90 days who are currently receiving the requested medication.

Documentation Required

Documentation of prior therapies and response required

Document and submit trials, durations, and outcomes (failure, contraindication, or intolerance) for the prior therapies required by the indication-specific criteria. This includes documentation of conventional therapies at maximally tolerated doses and prior biologic therapy (e.g., TNF blockers) or systemic alternatives as listed in the diagnosis-specific sections.

Applicable Codes

N/A (No procedure/CPT/HCPCS codes specified)mixed

No codes listed

Clinical Evidence & Sources

Upadacitinib (Rinvoq) is a Janus kinase (JAK) inhibitor available as extended-release tablets and an oral solution (Rinvoq LQ). The policy’s authorization criteria are aligned to FDA‑labeled indications and formulary management, including specialty designation and quantity limits. The policy also cautions against use in combination with other JAK inhibitors, biologic DMARDs, or potent immunosuppressants such as azathioprine and cyclosporine.

Source - Prescribing information: Rinvoq/Rinvoq LQ (upadacitinib) prescribing information, AbbVie Inc; April 2025.

Definitions & Thresholds

TNF blockers: examples include adalimumab, certolizumab pegol, etanercept, and golimumab.

Trial and failure: a documented adequate trial at a maximally tolerated dose with lack of therapeutic benefit, intolerance, or contraindication.

Clinical thresholds

Atopic dermatitis BSA/crucial areasAffected body surface >= 10% OR crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) affected

Topical steroid trial length14-day supply counts as trial for topical corticosteroid

Conventional therapy trial for RAMinimum 3-month trial and failure, contraindication, or intolerance to ONE conventional therapy (e.g., methotrexate, leflunomide, sulfasalazine) at maximally tolerated dose

pJIA conventional therapy trialMinimum duration 6-week trial and failure, contraindication, or intolerance to ONE conventional therapy (e.g., methotrexate, leflunomide) at maximally tolerated dose

Revision History

2024-09-11added

Added Rinvoq LQ to the policy and added criteria for pJIA; Rinvoq LQ only approved for psoriatic arthritis and pJIA. (Noted in review history.)

2024-10-09revised

Updated limitations to state Rinvoq LQ will only be approved for psoriatic arthritis and pJIA; timeline notes effective dates for LQ product-specific approvals.

2024-11-01added

Effective date for addition of Rinvoq LQ to policy (per review history).

Policy Summary

PayerMass General Brigham Health Plan

PolicyRinvoq (upadacitinib) Rinvoq LQ (updacitinib) Effective 07/01/2025 MassHealth UPPL

Policy CodePolicy N/A

Change TypeAdded product; revised indication criteria and reauthorization rules

Effective DateJul 1, 2025

Next Review Date

Key ActionPrior authorization is required for Rinvoq and Rinvoq LQ; submit documentation of prior therapy trials, durations, and failures and fill at a contracted specialty pharmacy as applicable.

SourceLink

On This Page

Documentation Required

Reauthorization evidence

For reauthorization, submit documentation demonstrating clinical improvement in the member's condition (for example, low disease activity or improvement in signs and symptoms such as clear or almost clear skin for atopic dermatitis).

Billing Rule

Quantity limits

Quantity limits apply: Rinvoq tablets (15 mg, 30 mg, 45 mg) — 1 tablet per day. Rinvoq LQ oral solution — 12 mL per day.

Prior Authorization

Product-specific restriction for Rinvoq LQ

Rinvoq LQ (oral solution) has a product-specific restriction: approvals for Rinvoq LQ are limited to psoriatic arthritis (PsA) and polyarticular juvenile idiopathic arthritis (pJIA).

NSAID trial for AS and nr-axSpAMinimum 1-month trial and failure, contraindication, or intolerance to TWO different NSAIDs (e.g., ibuprofen, naproxen) at maximally tolerated doses

2025-01-01revised

Effective date noted for updated nr-axSpA criteria requiring trial and failure with minimum 1 month and two NSAIDs.

2025-01-08revised

Updated atopic dermatitis criteria to require prior trial with either Adbry or Dupixent (change recorded in January review).

2025-03-12revised

March updates added appendix with corticosteroids and updated approval lengths for atopic dermatitis (effective 04/01/2025).

2025-04-01revised

Effective date for updated atopic dermatitis approval lengths and related changes.

2025-04-09revised

Updated atopic dermatitis criteria to include Ebglyss as a systemic single-step option (recorded April review).

2025-05-14revised

May review documented updates to Crohn's disease and ulcerative colitis criteria to allow approval if disease severity warrants systemic biologic as first-line therapy (effective 07/01/2025).

2025-07-01revisedLatest

Effective date for addition of Ebglyss into AD criteria and for updates to Crohn's disease and ulcerative colitis criteria as noted in review history.