Subject: Specialty Quantity Limit Rinvoq 3175-H P2021c
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. If the member’s
plan allows a quantity limit exception review for the requested
medication, coverage of an additional quantity may be
provided up to the exception limit with prior authorization.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
Exception Limit*
|
FDA-recommended dosing
|
|
Rinvoq (upadacitinib)
15 mg
extended-release
tablet
|
30 tablets
per 30 days
|
N/A
|
Rheumatoid arthritis, psoriatic arthritis, and
ankylosing spondylitis: 15 mg once daily
Atopic dermatitis:
• 15 mg once daily. If an adequate
response is not achieved, consider
increasing to 30 mg once daily.
• Dose adjustments: Reduce to 15 mg
once daily for patients:
ο 65 years of age and older
ο With severe renal impairment
ο Receiving strong CYP3A4 inhibitors
Ulcerative colitis
Induction dose of 45 mg once daily for
8 weeks
• Maintenance dose of 15 mg once daily.
A dosage of 30 mg once daily may be
considered for patients with refractory,
severe or extensive disease
• Dose adjustments: Induction dose of 30
mg once daily for 8 weeks and
maintenance dose of 15 mg once daily
for patients:
ο With severe renal impairment
ο With mild to moderate hepatic
impairment (Child-Pugh A or B)
ο Receiving strong CYP3A4 inhibitors
|
|
Rinvoq (upadacitinib)
30 mg extended-
release tablet
|
30 tablets
per 30 days
|
N/A
|
|
Rinvoq (upadacitinib)
45 mg extended-
release tablet
|
No standard
limit - only used
for induction
dosing
|
56 tablets per 56 days
|
*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.
Place of Service:
Outpatient
The above policy is based on the following references:
- Rinvoq [package insert]. North Chicago, IL: AbbVie Inc.; April 2022.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
June 26, 2022
