Rinvoq — Medica

Preferred products

• Enbrel
• adalimumab-adbm
• adalimumab-adaz
• adalimumab-ryvk
• Simlandi

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, or Simponi Aria counts)

Reauthorization criteria

• Patient meets the standard Inflammatory Conditions – Rinvoq/LQ Prior Authorization Policy criteria
• Patient continues to have Juvenile Idiopathic Arthritis and met step therapy requirement (Enbrel, adalimumab, Cimzia, infliximab, or Simponi Aria)

Approval duration

6 months initial, 1 year reauthorization