Rinvoq — United Healthcare

Initial criteria

• Diagnosis of active ankylosing spondylitis or non-radiographic axial spondyloarthritis
• EITHER (a) History of failure to two NSAIDs at maximally indicated doses, each used ≥4 weeks, unless contraindicated or adverse effects, OR previously treated with targeted immunomodulator FDA-approved for AS/nr-axSpA (e.g., Enbrel, Cimzia, adalimumab, Simponi, Xeljanz/XR) AND history of failure, contraindication, or intolerance to ≥1 TNF inhibitor OR documented needle-phobia; OR (b) Patient currently on Rinvoq therapy and has not received manufacturer sample/assistance
• Patient is not receiving Rinvoq in combination with either of the following: (a) Targeted immunomodulator [e.g., Enbrel, Cimzia, Simponi, Orencia, adalimumab, Xeljanz, Olumiant] OR (b) Potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)
• Prescribed by or in consultation with a rheumatologist

Reauthorization criteria

• Documentation of positive clinical response to Rinvoq therapy
• Patient is not receiving Rinvoq in combination with targeted immunomodulator [same list as initial] OR potent immunosuppressant

Approval duration

12 months