CurrentNeighborhood Health Plan of Rhode IslandPolicy 3173-A

Rinvoq, Rinvoq LQ

Defines prior authorization criteria, documentation requirements, prescriber specialty, duration of approvals, clinical continuation criteria, and exclusions for upadacitinib (Rinvoq) across FDA-approved indications (RA, PsA, atopic dermatitis, UC, AS, nr-axSpA, Crohn's disease, pJIA).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRinvoq, Rinvoq LQ

Policy CodePolicy 3173-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit chart notes, medical records, or claims history supporting prior medications and responses for initial requests; for continuation requests provide documentation of positive clinical response or remission.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or authorization criteria.

8FDA-approved indications listed

12 moTypical authorization duration

4 moAtopic dermatitis initial duration

Coverage Summary

This policy covers upadacitinib (Rinvoq) — all brands/generics and dosage forms — for FDA‑approved inflammatory and autoimmune indications when the authorization criteria are met. Prior to initiation, persons who are naïve to biologic or targeted‑synthetic agents associated with increased TB risk must have documented TB screening. Use of upadacitinib concomitantly with other biologic drugs, targeted synthetic JAK inhibitors, or potent immunosuppressants is not permitted.

Initial Therapy Criteria

General Covered Indications

Covered when ALL of the following are met:

ALL of the following

Requested drug is upadacitinib (Rinvoq) for an FDA-approved indication listed in this policy
Member has documentation supporting prior therapies tried and inadequate response or intolerance to required prior therapy as specified per indication
Prescriber is of required specialty for the indication (see Prescriber Specialties)
Member has documented negative TB test within 12 months prior to initiation if naïve to biologic or targeted synthetic drugs associated with increased TB risk; if positive, further testing to exclude active TB and treatment of latent TB before initiation
Member is not using concomitant biologic, targeted synthetic JAK inhibitor, or potent immunosuppressant (e.g., azathioprine, cyclosporine)

Rheumatoid arthritis (RA) - Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

ALL of the following

Adult member with moderately to severely active rheumatoid arthritis
Member has had an inadequate response, intolerance, or contraindication to at least one TNF inhibitor

Rheumatoid arthritis (RA) - Alternative prior therapy allowance

Authorization of 12 months may be granted when ANY of the following is met:

ANY of the following

Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug (e.g., Xeljanz, Olumiant) indicated for RA

Psoriatic arthritis (PsA) - Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

ALL of the following

Member is 2 years of age or older with active psoriatic arthritis
Member has had an inadequate response or intolerance to at least one TNF inhibitor

Psoriatic arthritis (PsA) - Alternative prior therapy allowance

Authorization of 12 months may be granted when ANY of the following is met:

ANY of the following

Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug (e.g., Xeljanz, Otezla) indicated for PsA

Ulcerative colitis (UC) - Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

ALL of the following

Adult member with moderately to severely active ulcerative colitis
Member has had an inadequate response or intolerance to at least one TNF inhibitor

Ulcerative colitis (UC) - Alternative prior therapy allowance

Authorization of 12 months may be granted when ANY of the following is met:

ANY of the following

Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug (e.g., Xeljanz) indicated for UC

Ankylosing spondylitis (AS) and nr-axSpA - Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

ALL of the following

Adult member with active ankylosing spondylitis or active non-radiographic axial spondyloarthritis
Member has experienced an inadequate response or intolerance to at least one TNF inhibitor

Ankylosing spondylitis (AS) and nr-axSpA - Alternative prior therapy allowance

Authorization of 12 months may be granted when ANY of the following is met:

ANY of the following

Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug (e.g., Xeljanz) indicated for AS or nr-axSpA

Crohn's disease (CD) - Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

ALL of the following

Adult member with moderately to severely active Crohn's disease
Member has had an inadequate response or intolerance to at least one TNF inhibitor

Crohn's disease (CD) - Alternative prior therapy allowance

Authorization of 12 months may be granted when ANY of the following is met:

ANY of the following

Member previously received a biologic (other than a TNF inhibitor) indicated for moderately to severely active Crohn's disease

Polyarticular juvenile idiopathic arthritis (pJIA) - Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

ALL of the following

Member is 2 years of age or older with active polyarticular juvenile idiopathic arthritis
Member has had an inadequate response or intolerance to at least one TNF inhibitor

Polyarticular juvenile idiopathic arthritis (pJIA) - Alternative prior therapy allowance

Authorization of 12 months may be granted when ANY of the following is met:

ANY of the following

Member previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for pJIA

Continuation / Renewal Criteria

Continuation / Renewal Criteria (by indication group)

Authorization of 12 months (or as specified) may be granted for members who achieve or maintain a positive clinical response as evidenced by improvement from baseline:

ANY of the following

RA: Improvement of at least 20% from baseline in tender joint count, swollen joint count, pain, or disability>= 20% improvement
PsA: Improvement in signs and symptoms (examples: number of swollen joints, tender joints, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, CRP)
Atopic dermatitis: Low disease activity (clear or almost clear skin) or improvement in signs/symptoms (e.g., redness, itching, oozing/crusting)
UC: Remission or improvement in stool frequency, rectal bleeding, urgency, CRP, fecal calprotectin, mucosal appearance on imaging/endoscopy, or disease activity scoring tool (e.g., UCEIS, Mayo)
AS / nr-axSpA: Low disease activity or improvement in functional status, total spinal pain, inflammation (e.g., morning stiffness), swollen/tender joints, CRP
CD: Remission or improvement in abdominal pain/tenderness, diarrhea, body weight, abdominal mass, hematocrit, mucosal appearance on imaging/endoscopy, or disease activity scoring tool (e.g., CDAI)
pJIA: Low disease activity or improvement in number of joints with active arthritis, limitation of movement, or functional ability

Typical authorizations are for 12 months for most FDA‑approved indications; initial approvals for atopic dermatitis are typically for 4 months. Continuation or renewal of therapy is contingent on documentation demonstrating a positive clinical response or maintenance of improvement as specified in the policy.

Provider Actions

Prior Authorization

Prior authorization required with documentation

Submit chart notes, medical records, or claims history supporting previous medications tried and responses (or clinical reason therapy is not advisable) for initial requests; for continuation requests submit documentation supporting positive clinical response or remission.

Initial: chart notes, medical records, or claims history showing prior meds/trials and responses or reasons therapy is not advisable
Continuation: documentation supporting positive clinical response or remission

Documentation Required

TB screening requirement

Document a negative TB test (TST or IGRA) within 12 months prior to initiation if naïve to biologic or targeted synthetic agents; if TB screening is positive, provide further testing to exclude active TB (e.g., chest x-ray), do not administer medication for active TB, and begin treatment for latent TB before initiating therapy.

Negative TST or IGRA within 12 months if biologic/targeted-synthetic–naïve
If positive: further testing to exclude active TB, do not start medication if active TB, treat latent TB before initiation

Documentation Required

Topical therapy documentation for atopic dermatitis

For atopic dermatitis pathway requiring topical therapy, document trials within the past year of a medium‑potency to super‑high potency topical corticosteroid, a topical calcineurin inhibitor, a topical JAK inhibitor, or a topical PDE‑4 inhibitor — or document a clinical reason these topical agents are not advisable.

Trial within past year of: medium to super‑high potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, or topical PDE‑4 inhibitor
Or: documentation that topical agents are not advisable (e.g., contraindication, prior intolerance)

Prior Authorization

Prescriber specialty restriction

Ensure prescriber is the required specialty or the request is made in consultation with the required specialty per 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 Crohn's disease.

Rheumatologist: RA, AS, nr‑axSpA, pJIA
Rheumatologist or dermatologist: PsA
Dermatologist or allergist/immunologist: atopic dermatitis
Gastroenterologist: UC and Crohn's disease

Billing Rule

Dosing limits

Approvals may be subject to dosing limits consistent with FDA‑approved labeling, accepted compendia, and evidence‑based practice guidelines.

Dosing limits follow FDA labeling, compendia, and evidence‑based guidelines

OpenPayer

Rinvoq, Rinvoq LQ

Coverage Summary

Initial Therapy Criteria

Continuation / Renewal Criteria

Not Medically Necessary / Experimental

Applicable Codes

Provider Actions

Clinical Evidence

Background

Revision History