Rinvoq LQ — United Healthcare

Undifferentiated arthritis (implied rheumatologic condition preceding Section H, likely continuation from previous chunk)

Initial criteria

(1) Patient is not receiving Rinvoq or Rinvoq LQ in combination with either of the following: (a) Targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Olumiant (baricitinib), Xeljanz (tofacitinib)] (b) Potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)
AND (4) Prescribed by or in consultation with a rheumatologist
Patients requesting initial authorization who were established on therapy via manufacturer sample or Abbvie Rinvoq Complete program assistance shall be required to meet initial authorization criteria as if new to therapy

(1) Documentation of positive clinical response to Rinvoq or Rinvoq LQ therapy
AND (2) Patient is not receiving Rinvoq or Rinvoq LQ in combination with either of the following: (a) Targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Olumiant (baricitinib), Xeljanz (tofacitinib)] (b) Potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)

12 months