UnitedHealthcare Rinvoq Prior Auth Policy Update | OpenPayer

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UnitedHealthcare Rinvoq Prior Auth Policy Update | OpenPayer

Coverage Criteria for Rinvoq (upadacitinib)

Initial Therapy — Rheumatoid Arthritis

Covered when ALL of the following are met

RA initial: (1) Diagnosis of moderately to severely active rheumatoid arthritis; (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor; (3) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, certolizumab, etanercept, abatacept, golimumab, tofacitinib); or (b) a potent immunosuppressant (e.g., azathioprine or cyclosporine).

Authorization will be issued for 12 months.

Continuation Therapy — Rheumatoid Arthritis

Covered when ALL of the following are met

RA reauthorization: (1) Documentation of positive clinical response to Rinvoq therapy; (2) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, certolizumab, etanercept, abatacept, golimumab, tofacitinib); or (b) a potent immunosuppressant (e.g., azathioprine or cyclosporine).

Authorization will be issued for 12 months.

Initial Therapy — Psoriatic Arthritis

Covered when ALL of the following are met

PsA initial: (1) Diagnosis of active psoriatic arthritis; (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor; (3) Patient is not receiving Rinvoq or Rinvoq LQ in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (examples include adalimumab, bimekizumab, certolizumab, secukinumab, etanercept, abatacept, apremilast, golimumab, risankizumab, ixekizumab, guselkumab, tofacitinib, ustekinumab); or (b) a potent immunosuppressant (e.g., azathioprine or cyclosporine).

Authorization will be issued for 12 months.

Continuation Therapy — Psoriatic Arthritis

Covered when ALL of the following are met

PsA reauthorization: (1) Documentation of positive clinical response to Rinvoq or Rinvoq LQ therapy; (2) Patient is not receiving Rinvoq or Rinvoq LQ in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (examples include adalimumab, bimekizumab, certolizumab, secukinumab, etanercept, abatacept, apremilast, golimumab, risankizumab, ixekizumab, guselkumab, tofacitinib, ustekinumab); or (b) a potent immunosuppressant (e.g., azathioprine or cyclosporine).

Authorization will be issued for 12 months.

Initial Therapy — Atopic Dermatitis

Covered when ALL of the following are met

AD initial: (1) Diagnosis of moderate-to-severe chronic atopic dermatitis; (2) Patient is 12 years of age or older; (3) History of failure, contraindication, or intolerance to at least one systemic drug product for the treatment of atopic dermatitis; (4) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., tralokinumab, dupilumab, abrocitinib, tofacitinib, baricitinib, topical ruxolitinib); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Continuation Therapy — Atopic Dermatitis

Covered when ALL of the following are met

AD reauthorization: (1) Documentation of positive clinical response to Rinvoq therapy; (2) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., tralokinumab, dupilumab, abrocitinib, tofacitinib, baricitinib, topical ruxolitinib); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Initial Therapy — Ulcerative Colitis

Covered when ALL of the following are met

UC initial: (1) Diagnosis of moderately to severely active ulcerative colitis; (2) History of an inadequate response or intolerance to at least one TNF inhibitor OR if TNF inhibitors are clinically inadvisable, patient received at least one approved systemic therapy; (3) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, vedolizumab, mirikizumab, golimumab, risankizumab, guselkumab, tofacitinib, ustekinumab, ozanimod); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Continuation Therapy — Ulcerative Colitis

Covered when ALL of the following are met

UC reauthorization: (1) Documentation of positive clinical response to Rinvoq therapy; (2) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, vedolizumab, mirikizumab, golimumab, risankizumab, guselkumab, tofacitinib, ustekinumab, ozanimod); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Initial Therapy - Ankylosing spondylitis / Non-radiographic axial spondyloarthritis

Covered when ALL of the following are met

AS/nr-axSpA initial: (1) Diagnosis of active ankylosing spondylitis or non-radiographic axial spondyloarthritis; (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor; (3) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, bimekizumab, certolizumab, secukinumab, etanercept, baricitinib, abatacept, golimumab, ixekizumab, tofacitinib); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Reauthorization - Ankylosing spondylitis / Non-radiographic axial spondyloarthritis

Covered when ALL of the following are met

AS/nr-axSpA reauth: (1) Documentation of positive clinical response to Rinvoq therapy; (2) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, bimekizumab, certolizumab, secukinumab, etanercept, baricitinib, abatacept, golimumab, ixekizumab, tofacitinib); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Initial Therapy - Crohn's disease

Covered when ALL of the following are met

Crohn's initial: (1) Diagnosis of moderately to severely active Crohn's disease; (2) History of an inadequate response or intolerance to at least one TNF inhibitor OR if TNF inhibitors are clinically inadvisable, patient received at least one approved systemic therapy; (3) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, certolizumab, vedolizumab, mirikizumab, risankizumab, guselkumab, ustekinumab); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Reauthorization - Crohn's disease

Covered when ALL of the following are met

Crohn's reauth: (1) Documentation of positive clinical response to Rinvoq therapy; (2) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, certolizumab, vedolizumab, mirikizumab, risankizumab, guselkumab, ustekinumab); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Initial Therapy - Polyarticular juvenile idiopathic arthritis

Covered when ALL of the following are met

pJIA initial: (1) Diagnosis of active polyarticular juvenile idiopathic arthritis; (2) History of failure, contraindication, or intolerance to at least one TNF inhibitor; (3) Patient is not receiving Rinvoq or Rinvoq LQ in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, certolizumab, etanercept, baricitinib, abatacept, golimumab, tofacitinib); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Reauthorization - Polyarticular juvenile idiopathic arthritis

Covered when ALL of the following are met

pJIA reauth: (1) Documentation of positive clinical response to Rinvoq or Rinvoq LQ therapy; (2) Patient is not receiving Rinvoq or Rinvoq LQ in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication (e.g., adalimumab, certolizumab, etanercept, baricitinib, abatacept, golimumab, tofacitinib); or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Initial Therapy - Giant cell arteritis

Covered when ALL of the following are met

GCA initial: (1) Diagnosis of giant cell arteritis; (2) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication; or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Reauthorization - Giant cell arteritis

Covered when ALL of the following are met

GCA reauth: (1) Documentation of positive clinical response to Rinvoq therapy; (2) Patient is not receiving Rinvoq in combination with either: (a) a systemic targeted immunomodulator for treatment of the same indication; or (b) a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil).

Authorization will be issued for 12 months.

Use of Rinvoq (upadacitinib) in combination with other systemic immune‑modulating therapies is restricted. Requests will not meet criteria when the patient is receiving Rinvoq or Rinvoq LQ in combination with a systemic targeted immunomodulator for the same indication (examples include, but are not limited to, adalimumab, vedolizumab, mirikizumab, golimumab, risankizumab, guselkumab, tofacitinib, ustekinumab, ozanimod, certolizumab, secukinumab, etanercept, baricitinib, abatacept, ixekizumab, bimekizumab).

Similarly, combination use with a potent immunosuppressant (examples include azathioprine, cyclosporine, mycophenolate mofetil) is not permitted under the authorization criteria. The policy language applies across indications (e.g., rheumatoid arthritis, psoriatic arthritis, atopic dermatitis, ulcerative colitis, ankylosing spondylitis, Crohn's disease, polyarticular JIA, giant cell arteritis) where the document specifically states the patient must not be receiving Rinvoq in combination with the listed agents.

Across the covered indications, the criteria consistently require that patients be not receiving Rinvoq (or Rinvoq LQ) in combination with either a systemic targeted immunomodulator for the same indication or a potent immunosuppressant. Examples of systemic targeted immunomodulators cited in the policy include adalimumab, vedolizumab, mirikizumab, certolizumab, golimumab, risankizumab, guselkumab, ustekinumab, secukinumab, etanercept, baricitinib, abatacept, ixekizumab, bimekizumab, tofacitinib/Xeljanz, and ozanimod.

This not-in-combination statement appears in initial and reauthorization criteria for multiple disease states (for example, rheumatoid arthritis, psoriatic arthritis, atopic dermatitis, ulcerative colitis, Crohn's disease, ankylosing spondylitis, non‑radiographic axial spondyloarthritis, polyarticular JIA, and giant cell arteritis) and is paired with an authorization period of 12 months where approval is granted.

Change history notes indicate that the policy wording related to combination therapy was clarified in a prior update: the phraseology was revised to reference targeted immunomodulators with updated examples. The change log documents these wording clarifications as updates to examples and language without altering the clinical intent of the restriction.

Provider Actions, Documentation, and Authorization Notes

Prior Authorization

Rheumatoid arthritis — Initial authorization

Rinvoq (upadacitinib) prior authorization is required. For rheumatoid arthritis (initial authorization) requests, submit documentation of the diagnosis of moderately to severely active RA and a history of failure, contraindication, or intolerance to at least one TNF inhibitor. Requests should also document that the patient is not receiving Rinvoq in combination with either (a) a systemic targeted immunomodulator (examples: adalimumab, Cimzia [certolizumab], Enbrel [etanercept], Orencia [abatacept], Simponi [golimumab], Xeljanz/Xeljanz XR [tofacitinib]) for treatment of the same indication; or (b) a potent immunosuppressant (examples: azathioprine or cyclosporine). Initial approvals are issued for 12 months.

Initial authorization: diagnosis of moderately to severely active RA; prior failure/contraindication/intolerance to ≥1 TNF inhibitor
Combination therapy exclusion: not receiving Rinvoq with systemic targeted immunomodulator for same indication (e.g., adalimumab, certolizumab, etanercept, abatacept, golimumab, tofacitinib)
Combination therapy exclusion: not receiving Rinvoq with potent immunosuppressant (e.g., azathioprine, cyclosporine)
Authorization duration: 12 months

Definitions and Limitations of Use

Limitation of Use — Combination therapy prohibition

Limitation of Use (general)Rinvoq/Rinvoq LQ is not recommended for use in combination with other JAK inhibitors, biologic DMARDs, or with potent immunosuppressants such as azathioprine and cyclosporine.

Examples of potent immunosuppressantsAzathioprine and cyclosporine are specifically listed as examples of potent immunosuppressants that should not be used in combination with Rinvoq.

Disease-specific combination guidanceThe limitation applies across indicated conditions (e.g., RA, PsA, AD, UC, AS, Crohn's disease, pJIA, GCA) — Rinvoq is repeatedly stated as not recommended in combination with the listed agents for these indications.

Action for inadequate responseSeparate limitation language notes therapeutic management (e.g., discontinue if inadequate response at 30 mg for some indications) and to use the lowest effective dose to maintain response — combination avoidance remains recommended.

Rinvoq (upadacitinib) — Package insert

Background

Rinvoq (upadacitinib) is a Janus kinase (JAK) inhibitor approved for multiple immune‑mediated inflammatory diseases. Indications referenced in the policy include rheumatoid arthritis, psoriatic arthritis, atopic dermatitis, ulcerative colitis, ankylosing spondylitis, non‑radiographic axial spondyloarthritis, Crohn's disease, polyarticular juvenile idiopathic arthritis, and giant cell arteritis. The package insert is cited as the primary drug reference for clinical details and dosing.

The policy reiterates the product's limitation of use: Rinvoq is not recommended for use in combination with other JAK inhibitors, biologic DMARDs/biological therapies for inflammatory bowel disease, or potent immunosuppressants (for example, azathioprine and cyclosporine). This limitation is applied consistently across adult and pediatric indications in the coverage criteria.

Policy Change History