CurrentNeighborhood Health Plan of Rhode IslandPolicy 3173-A

Rinvoq (upadacitinib) coverage and prior authorization policy

Defines covered FDA-approved indications for upadacitinib (Rinvoq), documentation required for initial and continuation prior authorization, prescriber specialty requirements, indication-specific clinical criteria for coverage durations, TB screening and concomitant therapy exclusions, and dosing/administration note about dosing limits per labeling.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRinvoq (upadacitinib) coverage and prior authorization policy

Policy CodePolicy 3173-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization with chart notes/medical records documenting prior medications tried and response (initial AD requests must include affected area(s) and BSA where applicable).

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage criteria or policy terms for upadacitinib (Rinvoq) in this brief.

9Explicit covered indications listed

12 moTypical authorization duration

4 moAD initial authorization

≤12 moTB test recency required

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General Indication Coverage

The following FDA‑approved indications are considered covered when ALL criteria are met:

ALL of the following

Psoriatic arthritis (PsA): Authorization of 12 months may be granted for members 2 years of age or older for treatment of active psoriatic arthritis when the member has had an inadequate response or intolerance to at least one TNF inhibitor.
Psoriatic arthritis (PsA) — alternate pathway: Authorization of 12 months may be granted for members 2 years of age or older who have previously received a biologic (other than a TNF inhibitor) or a targeted synthetic drug (e.g., Xeljanz, Otezla) indicated for active psoriatic arthritis.
Atopic dermatitis (AD): Authorization of 4 months may be granted for members 12 years of age or older for treatment of moderate‑to‑severe atopic dermatitis when the member has had an inadequate response or intolerance to at least one biologic (e.g., Adbry, Dupixent; Ebglyss, Nemluvio) or a systemic targeted synthetic drug (e.g., Cibinqo) in the past year.
Atopic dermatitis (AD) — disease extent: Affected body surface area (BSA) is ≥ 10% OR crucial body areas (e.g., hands, feet; face, neck, scalp, genitals/groin, intertriginous areas) are affected.
Atopic dermatitis (AD) — topical/systemic failure or contraindication: Member has tried and had inadequate response or intolerance to, or has a documented contraindication or intolerance to, medium‑to‑super high potency topical corticosteroid therapy and at least one of the following within the past year: topical calcineurin inhibitor, topical phosphodiesterase‑4 (PDE‑4) inhibitor, or topical JAK inhibitor; AND/OR member has had an inadequate response or intolerance to a biologic or systemic targeted synthetic drug indicated for AD.
Ulcerative colitis (UC): Authorization of 12 months may be granted for treatment of moderately to severely active UC when the member has had an inadequate response or intolerance to at least one TNF inhibitor.
Ulcerative colitis (UC) — alternate pathway: Authorization of 12 months may be granted for members who have previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug (e.g., Xeljanz) indicated for moderately to severely active UC.
Ankylosing spondylitis (AS) and non‑radiographic axial spondyloarthritis (nr‑axSpA): Authorization of 12 months may be granted for adult members for treatment of active AS or active nr‑axSpA when the member has experienced an inadequate response or intolerance to at least one TNF inhibitor.
Ankylosing spondylitis (AS) / nr‑axSpA — alternate pathway: Authorization of 12 months may be granted for adult members who have previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug (e.g., Xeljanz) indicated for active AS or nr‑axSpA.
Crohn's disease (CD): Authorization of 12 months may be granted for treatment of moderately to severely active CD when the member has had an inadequate response or intolerance to at least one TNF inhibitor.
Crohn's disease (CD) — alternate pathway: Authorization of 12 months may be granted for members who have previously received a biologic (other than a TNF inhibitor) indicated for moderately to severely active CD.
Polyarticular juvenile idiopathic arthritis (pJIA): Authorization of 12 months may be granted for members 2 years of age or older for treatment of active pJIA when the member has had an inadequate response or intolerance to at least one TNF inhibitor.
Polyarticular juvenile idiopathic arthritis (pJIA) — alternate pathway: Authorization of 12 months may be granted for members 2 years of age or older who have previously received a biologic (other than a TNF inhibitor) or targeted synthetic drug indicated for active pJIA.
General requirements and notes: Baseline and periodic documentation must support prior therapies tried (chart notes, medical records, or claims history) or a documented clinical reason why such therapies are not advisable. Continuation approvals require chart notes demonstrating positive clinical response as defined in the policy. Prescriber specialty requirements apply by indication (e.g., rheumatologist for RA, gastroenterologist for UC/CD, dermatologist for AD, etc.). TB screening is required prior to initiation; avoid concomitant use with other biologic/JAK therapies unless specified and clinically justified.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior authorization required

Initial and continuation prior authorization is required. Submit chart notes, medical records, or claims history documenting prior medications tried and response, or a clinical reason therapy is not advisable. For initial atopic dermatitis requests, include documentation of affected area(s) and body surface area (BSA) where applicable.

Initial and continuation requests require prior authorization
Include chart notes/medical records/claims history documenting prior medications tried and response or clinical reason to avoid therapy
Initial AD requests must include affected area(s) and BSA

Documentation Required

TB screening documentation

Document a negative tuberculosis (TB) test (TST or IGRA) within 12 months prior to initiating therapy. If screening is positive, provide further testing to exclude active disease (e.g., chest X‑ray) and document treatment of latent TB before starting therapy.

Negative TST or IGRA within 12 months required
If positive, further testing to exclude active TB (e.g., chest X‑ray)
If latent TB, treatment must be started before initiation

Documentation Required

Continuation documentation

For continuation requests, submit chart notes or medical record documentation supporting a positive clinical response as defined for the specific indication (e.g., symptom improvement, disease activity scores, remission).

Chart notes/medical records demonstrating positive clinical response
Use indication‑specific measures (e.g., joint counts, symptom scores, remission criteria)

Documentation Required

Prescriber specialty requirement

Ensure the medication is prescribed by—or in consultation with—an appropriate specialist for the indication. Required prescriber specialties include rheumatologist, dermatologist, allergist/immunologist, or gastroenterologist as specified by condition.

Rheumatologist for RA, AS, nr‑axSpA, pJIA
Dermatologist or allergist/immunologist for atopic dermatitis
Rheumatologist or dermatologist for PsA
Gastroenterologist for 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 per FDA labeling, compendia, and guidelines may apply

Clinical Evidence & Background

Background: Upadacitinib (Rinvoq) is FDA-approved for multiple inflammatory indications including RA, PsA, AD, UC, AS, nr-axSpA, Crohn's disease, and pJIA. Coverage requires prior therapy trials with documentation of inadequate response, intolerance, or contraindication (commonly at least one TNF inhibitor) as specified per indication. For all indications, a documented negative TB test (TST or IGRA) within 12 months prior to initiating therapy is required; if positive, further evaluation to exclude active disease (e.g., chest X-ray) and treatment of latent TB must be completed prior to initiation. Members must not receive concomitant biologic drugs, targeted synthetic agents, or potent immunosuppressants (e.g., azathioprine, cyclosporine) while on upadacitinib. Prescriptions should be by or in consultation with the required specialist for the indication. Primary reference: Rinvoq package insert, AbbVie, April 2024.

Quick Facts & Clinical Thresholds

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

Rheumatoid arthritis response threshold>= 20% improvement from baseline in tender joint count, swollen joint count, pain, or disability

Typical authorization duration (most indications)12 months

Atopic dermatitis initial authorization duration4 months

Required TB test recencyDocumented negative TST or IGRA within 12 months prior to initiating therapy

Definitions

Definition — Positive clinical response (general): indication-specific improvement such as remission, low disease activity, or measurable improvement in signs/symptoms or disease activity indices as described per condition (examples include ≥20% improvement in RA joint counts/pain/disability; reduction to low disease activity or improvements in swollen/tender joints, dactylitis, enthesitis, CRP for PsA; clear or almost clear skin or symptom improvement for AD; remission or improvements in stool frequency, rectal bleeding, CRP, endoscopic appearance, or fecal calprotectin for UC; improvements in pain, function, swollen joints, morning stiffness, or CRP for AS/nr-axSpA; remission or improvements in abdominal pain, diarrhea, weight, hematocrit, mucosal appearance, or CDAI for Crohn's disease; and reduced number of active joints or improved function for pJIA).

OpenPayer

Rinvoq (upadacitinib) coverage and prior authorization policy

Coverage Summary & Indications

Initial Therapy Criteria (by indication)

Continuation Therapy Criteria

Not Medically Necessary / Experimental

Provider Actions & Prior Authorization Requirements

Applicable Codes

Clinical Evidence & Background

Definitions

Revision History