upadacitinib — United Healthcare

Rheumatoid Arthritis

Preferred products

Diagnosis of moderately to severely active rheumatoid arthritis
AND One of the following:
(a) BOTH of the following:
• EITHER history of failure to a 3 month trial of one non-biologic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine) at maximally indicated doses, unless contraindicated or experienced clinically significant adverse effects OR previously treated with an FDA-approved targeted immunomodulator for rheumatoid arthritis (e.g., Enbrel, Cimzia, adalimumab, Simponi, Orencia, Olumiant, 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 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 with either:
(a) Targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, Orencia, adalimumab, Xeljanz, Olumiant)
(b) Potent immunosuppressant (e.g., azathioprine or cyclosporine)
AND Prescribed by or in consultation with a rheumatologist

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

12 months