upadacitinib — United Healthcare

Psoriatic Arthritis

Preferred products

Diagnosis of active psoriatic arthritis
AND One of the following:
(a) BOTH of the following:
• EITHER history of failure to a 3 month trial of methotrexate at maximally indicated dose unless contraindicated or experienced clinically significant adverse effects OR previously treated with an FDA-approved targeted immunomodulator for psoriatic arthritis (e.g., Enbrel, Cimzia, adalimumab, Simponi, Orencia, Stelara, Skyrizi, Tremfya, Cosentyx, Taltz, Olumiant, Otezla, Xeljanz/Xeljanz XR)
AND • EITHER history of failure, contraindication, or intolerance to at least one TNF inhibitor OR documented needle-phobia per DSM-V-TR 300.29
OR (b) BOTH of the following:
i. Patient currently on Rinvoq or Rinvoq LQ therapy as documented by claims or medical records
ii. Patient has not received a manufacturer supplied sample or Rinvoq Complete program assistance as means of establishing current use
AND Patient is not receiving Rinvoq or Rinvoq LQ with either:
(a) Targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, Orencia, adalimumab, Stelara, Skyrizi, Tremfya, Cosentyx, Taltz, Xeljanz, Olumiant, Otezla)
(b) Potent immunosuppressant (e.g., azathioprine or cyclosporine)
AND Prescribed by or in consultation with a rheumatologist or dermatologist

Documentation of positive clinical response to Rinvoq or Rinvoq LQ therapy
Patient is not receiving in combination with targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, Orencia, adalimumab, Stelara, Skyrizi, Tremfya, Cosentyx, Taltz, Xeljanz, Olumiant, Otezla) or potent immunosuppressant (e.g., azathioprine or cyclosporine)

12 months