Rinvoq — Medica
Ankylosing Spondylitis
Preferred products
- Enbrel
- adalimumab-adbm
- adalimumab-adaz
- adalimumab-ryvk
- Simlandi
- Taltz
Initial criteria
- Patient meets the standard Inflammatory Conditions – Rinvoq/LQ Prior Authorization Policy criteria
- Patient has tried ONE of Enbrel or an adalimumab product (or Cimzia, infliximab product, or Simponi counts)
Reauthorization criteria
- Patient meets the standard Inflammatory Conditions – Rinvoq/LQ Prior Authorization Policy criteria
- Patient continues to have Ankylosing Spondylitis and met step therapy requirement (tried Enbrel, adalimumab, Cimzia, infliximab, or Simponi)
Approval duration
6 months initial, 1 year reauthorization