Rinvoq — United Healthcare

Initial criteria

• Diagnosis of moderately to severely active ulcerative colitis
• EITHER (a) Patient has had prior or concurrent inadequate response to a therapeutic course of oral corticosteroids and/or immunosuppressants (e.g., azathioprine, 6-mercaptopurine) OR has been previously treated with a targeted immunomodulator FDA-approved for UC (e.g., adalimumab, Simponi, Stelara, Xeljanz/XR) AND has history of failure, contraindication, or intolerance to at least one TNF inhibitor OR has documented needle-phobia; OR (b) Patient is currently on Rinvoq therapy (document drug, date, duration) 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, Stelara, Skyrizi] OR (b) Potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)
• Prescribed by or in consultation with a gastroenterologist

Reauthorization criteria

• Documentation of positive clinical response to Rinvoq therapy
• Patient is not receiving Rinvoq in combination with either of the following: (a) Targeted immunomodulator [same list as initial] OR (b) Potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)

Approval duration

12 months