CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Rinvoq (upadacitinib) coverage and prior authorization criteria

Defines prior authorization, clinical eligibility, documentation, prescriber specialties, authorization durations, and renewal criteria for Rinvoq (upadacitinib) across FDA-approved indications; excludes non‑FDA and non‑compendial uses as investigational.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRinvoq (upadacitinib) coverage and prior authorization criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization with required documentation (chart notes, medication history, responses to prior therapies) for initial and continuation requests per indication.

POLICY UPDATE CHANGES

No material clinical/coverage changes — policy content remains current.

8FDA-approved indications listed

12mTypical authorization duration (most indications)

4mAuthorization duration for initial atopic dermatitis route

Coverage Summary

Covered Indications (general)

Covered when ALL of the following are met:

ALL of the following

Member has a diagnosis matching an FDA‑approved or compendial indication (e.g., moderately to severely active rheumatoid arthritis, active psoriatic arthritis, moderate‑to‑severe atopic dermatitis, moderately to severely active ulcerative colitis, moderately to severely active Crohn’s disease, active ankylosing spondylitis or non‑radiographic axial spondyloarthritis, or polyarticular juvenile idiopathic arthritis).
Member has had an inadequate response or intolerance to at least one tumor necrosis factor (TNF) inhibitor, unless documentation explains why TNF inhibitor therapy is not advisable (initial requests require prior therapy documentation).
For atopic dermatitis, when applicable: affected body surface area ≥ 10% or involvement of crucial body areas, plus inadequate response or intolerance to at least one biologic (e.g., dupilumab) or targeted synthetic agent, or documentation that those therapies are not advisable.
Documentation submitted: chart notes, medical records, or claims history showing diagnosis, prior therapies tried and responses for initial requests; for continuation requests, chart notes documenting positive clinical response or maintenance of low disease activity/remission.
TB exclusion: active tuberculosis must be ruled out prior to initiation per labeling and local infectious disease guidance.
Operational note: ensure latent TB screening and documentation as required by product labeling.
Concomitant therapy prohibition: concomitant use with agents contraindicated by product labeling or clinically inadvisable combinations is not permitted.
Prescriber specialty requirements: medication must be prescribed by or in consultation with an appropriate specialist based on indication — rheumatologist for RA, AS, nr‑axSpA, and pJIA; rheumatologist or dermatologist for PsA; dermatologist or allergist/immunologist for atopic dermatitis; gastroenterologist for UC and CD.
Dosing limits: therapy must be dosed per FDA‑approved labeling; authorizations are generally for up to 12 months for most indications (RA, PsA, UC, CD, AS, nr‑axSpA, pJIA) and up to 4 months for atopic dermatitis initial authorization where specified. Renewal requires documentation of positive clinical response (eg, ≥20% improvement in RA tender/swollen joint counts or other disease‑specific response measures).
Operational note: confirm dose and duration on the PA request; doses outside labeled ranges will be reviewed and may be denied.

Documentation Requirements for PA Review

Prior Authorization

Prior authorization required

Submit prior authorization with required documentation (chart notes, medication history, responses to prior therapies) for initial and continuation requests per indication.

Initial requests: Chart notes, medical record documentation, or claims history supporting previous medications tried (if applicable), including response to therapy. (see Documents by indication)
Continuation requests: Chart notes or medical record documentation supporting positive clinical response (see Documents by indication)

Documentation Required

TB screening documentation

Provide documented negative TB test (TST or IGRA) within 6 months for biologic/targeted-synthetic naive patients; if positive, provide confirmatory testing to exclude active TB (e.g., chest X-ray) and documentation of latent TB treatment prior to initiation. Do not administer Rinvoq to members with active TB infection.

Documentation Required

Evidence of prior therapy or contraindication

Provide prior medication trial history including responses; if prerequisite therapies are not advisable, supply clinical justification.

Documentation Required

Prescriber specialty attestation

Ensure Rinvoq is prescribed by or in consultation with the appropriate specialist for the indication (rheumatologist, dermatologist, allergist/immunologist, gastroenterologist).

Rheumatologist: rheumatoid arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, polyarticular juvenile idiopathic arthritis
Rheumatologist or dermatologist: psoriatic arthritis
Dermatologist or allergist/immunologist: atopic dermatitis
Gastroenterologist: ulcerative colitis and Crohn's disease

Denial Risk

Concomitant therapy contraindication

Claims may be denied if member is receiving concomitant biologic, targeted synthetic drug, or potent immunosuppressant (e.g., azathioprine, cyclosporine) with Rinvoq.

Examples of disallowed concomitant therapies: azathioprine, cyclosporine

Background and Definitions

This policy governs coverage of upadacitinib (Rinvoq) for FDA‑approved indications and requires prior authorization for clinical eligibility, documentation of prior therapies/responses, and appropriate prescriber specialty. Pediatric age limits apply for certain indications (for example, ≥2 years for PsA and pJIA; ≥12 years for atopic dermatitis). Documented negative TB testing (TST or IGRA) within 6 months is required prior to initiation for biologic/targeted‑synthetic‑naive patients, and latent TB must be treated before starting therapy. Approval durations align with indication‑specific guidance (most indications up to 12 months, with an initial 4‑month authorization pathway for certain atopic dermatitis scenarios) and continuation/renewal requires documentation of clinical improvement or maintenance of remission.

Term	Definition
BSA	Body Surface Area
TNF inhibitor	Tumor necrosis factor blocker agent

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRinvoq (upadacitinib) coverage and prior authorization criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization with required documentation (chart notes, medication history, responses to prior therapies) for initial and continuation requests per indication.

On This Page

OpenPayer

Rinvoq (upadacitinib) coverage and prior authorization criteria

Coverage Summary

Initial Therapy Criteria

Continuation / Renewal Criteria

Documentation Requirements for PA Review

Applicable Codes

Screening, Dosing Limits, and Contraindications

Background and Definitions

Clinical Evidence & References

Key Thresholds

Revision History