RINVOQ (upadacitinib) prior authorization for atopic dermatitis
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Defines prior authorization requirements for RINVOQ (upadacitinib) use in moderate to severe atopic dermatitis for Mississippi Division of Medicaid members, including initial and reauthorization criteria and dosing limits.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Initial Therapy — Initial Authorization: 6 Months
Initial Authorization: 6 Months. Covered when ALL of the following are met:
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inv-02: Continuation Therapy — Re-Authorization: 1 Year
Re-Authorization: 1 Year. Continued coverage when ALL of the following are met:
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Use of RINVOQ (upadacitinib) for atopic dermatitis must follow the FDA-indicated age and weight parameters in the package insert. The policy requires that the patient "meet the minimum age and weight requirements recommended by the package insert for this FDA approved indication" as a condition of initial authorization. Applications that propose use outside these FDA‑indicated age/weight parameters will be excluded unless the package‑insert requirements are satisfied.
Prior authorization is required for RINVOQ for atopic dermatitis. Approval is considered when all specified criteria are met, including: age/weight per the package insert, diagnosis of moderate to severe chronic atopic dermatitis with ≥10% body surface area involvement, prescribing by or in consultation with a dermatologist/allergist/immunologist (or other AD specialist), documented topical and systemic therapy trials as detailed in the criteria, and dosing within the limits specified by this policy.
Dosing beyond 30 mg once daily is not supported by the authorization criteria. The policy explicitly requires that the prescribed RINVOQ dose "does not exceed 30mg once daily" for initial approval and continuation; requests for doses above this threshold should be expected to be denied unless the prescriber documents rationale consistent with the package insert and prior authorization requirements.
Initial Drug Authorization
inv-13: Initial Drug Authorization — Initial authorization (6 months) requires:
Initial authorization (6 months) requires:
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Reauthorization Criteria
inv-14: Reauthorization — Re-authorization criteria for ongoing RINVOQ therapy (1 year):
Re-authorization criteria for ongoing RINVOQ therapy (1 year):
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Provider Actions & Requirements
Prior authorization required for RINVOQ in atopic dermatitis
Prior authorization is required for RINVOQ (upadacitinib) for atopic dermatitis. Approval will be considered when all listed criteria are met, including meeting package‑insert age/weight, diagnosis of moderate to severe chronic atopic dermatitis with ≥10% BSA, specialist prescriber or consultation, required prior topical and systemic therapy trials, and a prescribed dose ≤30 mg once daily.
Required topical and systemic prior therapy trials
Documented trials of specified topical and systemic therapies are required unless contraindicated: for moderate AD both a ≥2‑week trial of a preferred medium to very‑high potency topical corticosteroid within the past 90 days and a ≥4‑week trial of a preferred topical calcineurin inhibitor or crisaborole within the past 90 days; for severe AD both a ≥2‑week trial of a preferred medium to very‑high potency topical corticosteroid within the past 90 days and a ≥4‑week trial of a preferred topical calcineurin inhibitor within the past 90 days. In addition, at least a four‑week trial with inadequate response or intolerance to at least one systemic therapy is required unless contraindicated.
- Moderate AD: ≥2 weeks inadequate response to one preferred medium to very‑high potency topical corticosteroid (within past 90 days) AND ≥4 weeks inadequate response to one preferred topical calcineurin inhibitor or crisaborole (within past 90 days).
- Severe AD: ≥2 weeks inadequate response to one preferred medium to very‑high potency topical corticosteroid (within past 90 days) AND ≥4 weeks inadequate response to one preferred topical calcineurin inhibitor (within past 90 days).
- Systemic: ≥4 weeks trial with inadequate response or intolerance to at least one systemic therapy unless contraindicated.
Submit Universal PA Form and supporting clinical documentation
Submit the Universal PA Form along with supporting clinical documentation that demonstrates the diagnosis, percent body surface area affected, prior therapy trials (including durations and dates), prescriber specialty or documentation of consultation, and the prescribed RINVOQ dose.
Denial triggers if criteria or documentation are incomplete
Requests will be denied if required criteria are not met, including failure to meet package‑insert age/weight, BSA <10%, lack of documented required topical or systemic therapy trials, prescribing clinician not a specialist or lacking documented consultation, prescribed dose exceeding 30 mg once daily, or missing supporting documentation.
- Age/weight not consistent with package insert for the AD indication.
- Documented BSA is less than 10%.
- Required topical and/or systemic therapy trials are not documented or insufficient.
- Prescriber is not a dermatologist/allergist/immunologist/AD specialist and no consultation documented.
- Prescribed RINVOQ dose exceeds 30 mg once daily.
- Supporting clinical documentation (PA form, trial dates, responses) not provided.
Coding & Clinical Thresholds
Step Therapy Requirements
| Step | Requirement |
|---|---|
| 1 | Documented trial of a preferred medium to very‑high potency topical corticosteroid for at least 2 weeks with inadequate response within the past 90 days. |
| 2 | Documented trial of a preferred topical calcineurin inhibitor or EUCRISA (crisaborole) for at least 4 weeks with inadequate response within the past 90 days (for moderate AD: calcineurin inhibitor or crisaborole; for severe AD: calcineurin inhibitor). |
| 3 | At least a 4‑week trial with inadequate response or intolerance to at least one systemic therapy, unless contraindicated. |
Quantity Limits & Dosing
Definitions
Background
RINVOQ (upadacitinib) is a Janus kinase (JAK) inhibitor approved for multiple inflammatory conditions, including refractory moderate to severe atopic dermatitis in patients 12 years and older whose disease is not controlled with other systemic therapies or when such therapies are inadvisable. In the context of this policy, RINVOQ is considered for patients with moderate to severe chronic atopic dermatitis who meet the package‑insert age/weight requirements and the policy’s prior‑therapy, specialty prescriber, and disease‑severity criteria.
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