By Counterforce Health Team in Rinvoq (upadacitinib) —

How to Get Rinvoq (upadacitinib) Covered by Blue Cross Blue Shield in New York: Complete Guide to Forms, Appeals & Approval

Answer Box: Getting Rinvoq Covered by BCBS New York

Blue Cross Blue Shield New York requires prior authorization for Rinvoq (upadacitinib), typically with step therapy requirements. Your fastest path to approval: (1) Have your doctor complete the BCBS PA form with detailed medical necessity documentation, (2) Submit through the Availity portal or fax to 1-800-964-3627, and (3) If denied, file an internal appeal within 180 days, then external appeal with NY Department of Financial Services within 4 months. Start by verifying your specific BCBS plan and downloading the current PA form from your plan's provider portal.

Table of Contents

  1. Start Here: Verify Your Plan & Find Forms
  2. Required Forms & Documentation
  3. Submission Portals & Methods
  4. Specialty Pharmacy Setup
  5. Appeals Process in New York
  6. Support Contacts & Resources
  7. Costs & Patient Assistance
  8. FAQ

Start Here: Verify Your Plan & Find Forms

Before requesting Rinvoq coverage, confirm your exact Blue Cross Blue Shield plan. New York has multiple BCBS entities including Anthem/Empire BlueCross BlueShield, Excellus BCBS (upstate), and Highmark BCBS (western regions). Each may have slightly different forms and procedures.

Your insurance card should show:

  • Plan name (Commercial, Medicare Advantage, or Medicaid Managed Care)
  • Group number and member ID
  • Pharmacy benefits manager (often CVS Caremark)
Tip: Call the member services number on your card to confirm your plan's specific prior authorization requirements for specialty medications.

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all indications Plan formulary BCBS Provider Portal
Step Therapy Try TNF inhibitors first (unless contraindicated) PA criteria document FEP Blue Policy
Specialty Pharmacy Must use in-network specialty pharmacy Plan directory Plan-specific
Age Requirements Varies by indication (18+ for most) FDA labeling FDA-approved indications
Appeal Deadline 180 days (internal), 4 months (external) Plan documents NY DFS

Required Forms & Documentation

Prior Authorization Form

Your doctor must complete a BCBS-specific prior authorization form. For Excellus BCBS (covering much of upstate New York), download forms from their Medicare prior authorization page. Commercial plans use similar forms available through provider portals.

Required Documentation:

  • Diagnosis: ICD-10 codes for approved conditions (rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, Crohn's disease, ankylosing spondylitis, atopic dermatitis, or vitiligo)
  • Previous treatments: Documentation of failed or contraindicated TNF inhibitors or other preferred biologics
  • Lab results: Recent CBC, liver function tests, tuberculosis screening
  • Clinical notes: Treatment history, response to previous therapies, contraindications to step therapy

Medical Necessity Letter Checklist

Your prescriber should include:

✅ Problem statement: Specific diagnosis with severity/functional impact
✅ Treatment history: Previous medications tried, duration, outcomes, reasons for discontinuation
✅ Clinical rationale: Why Rinvoq is medically necessary vs. formulary alternatives
✅ Guideline support: Reference to ACR, AAD, or other relevant society guidelines
✅ Safety assessment: Documentation of infection screening, cardiovascular risk evaluation
✅ Monitoring plan: Lab monitoring schedule and follow-up appointments

Clinician Corner: BCBS policies require documentation that patients don't have active infections, severe hepatic impairment, or history of thrombotic events. Include specific lab values and dates of screening tests.

Submission Portals & Methods

Electronic Submission (Preferred)

Availity Portal: Most BCBS New York plans accept PA requests through Availity. Your doctor's office should:

  1. Log into the Availity provider portal
  2. Select "Prior Authorization"
  3. Choose your specific BCBS plan
  4. Complete the electronic form
  5. Upload supporting documents (clinical notes, labs, prior therapy records)

Fax Submission

Primary fax number: 1-800-964-3627 (for most prior authorization requests)

Specialty medication fax: 1-844-493-9206 (for medical injectables if applicable)

Cover sheet essentials:

  • Member name and ID
  • Provider name and NPI
  • "URGENT" if expedited review needed
  • Page count
  • Contact phone for questions

Processing Times

  • Standard review: 7-14 business days
  • Expedited review: 72 hours (requires physician attestation of urgency)
  • Incomplete submissions: May take 30+ days with back-and-forth requests

Specialty Pharmacy Setup

Rinvoq must be dispensed through a BCBS-contracted specialty pharmacy. Your plan will coordinate this, but you can expedite the process:

Steps to Set Up Specialty Pharmacy:

  1. After PA approval: Your doctor sends the prescription to the designated specialty pharmacy
  2. Patient enrollment: The pharmacy calls you within 24-48 hours to:
    • Verify insurance and copay information
    • Schedule delivery (usually monthly)
    • Provide medication counseling
    • Set up adherence monitoring
  3. First shipment: Typically arrives within 3-5 business days of enrollment

Common BCBS Specialty Pharmacy Partners:

  • CVS Specialty
  • Express Scripts Specialty
  • Accredo (Evernorth)
Note: Never fill Rinvoq at a retail pharmacy initially—it will be rejected. Always confirm your plan's specialty pharmacy network first.

Appeals Process in New York

If your initial PA request is denied, New York provides robust appeal rights with specific timelines.

Internal Appeal (Required First Step)

Timeline: Must file within 180 days of denial
Process: Submit appeal through your plan's member portal or by mail
Decision timeframe: 30 days (72 hours if expedited)

What to include:

  • Copy of denial letter
  • Additional medical records not previously submitted
  • Physician letter addressing specific denial reasons
  • Published medical literature supporting off-label use (if applicable)

External Appeal with NY Department of Financial Services

If your internal appeal is denied, you have powerful rights under New York law.

Key Details:

  • Deadline: 4 months from final internal denial
  • Fee: $25 (waived for Medicaid or financial hardship)
  • Decision binding: Insurer must comply if overturned
  • Expedited option: 24-72 hours for urgent cases

How to file: Complete the DFS external appeal form online or by mail.

Success factors:

  • Include all medical records
  • Provide peer-reviewed literature
  • Submit physician attestation for expedited review
  • Reference FDA labeling for approved indications
From our advocates: We've seen external appeals succeed when patients include recent clinical studies showing Rinvoq's effectiveness for their specific condition, especially when step therapy drugs caused serious side effects. The key is comprehensive documentation of why preferred alternatives aren't appropriate.

Support Contacts & Resources

BCBS New York Contact Numbers

Anthem/Empire BCBS:

  • Member Services: 1-800-EMPIRE1 (1-800-367-4731)
  • Provider Services: 1-800-450-8753
  • Prior Authorization Fax: 1-800-964-3627

Excellus BCBS (Upstate):

  • Member Services: 1-877-883-9577
  • Provider line for PA questions: Check provider portal

Highmark BCBS (Western NY):

  • Member Services: 1-866-231-0847
  • Provider Services: Same number

New York State Resources

Department of Financial Services:

Community Health Advocates:

  • Free insurance help: 1-888-614-5400
  • Assists with appeals and understanding rights

Costs & Patient Assistance

AbbVie Patient Support

AbbVie Care: Provides copay assistance and case management

  • Enrollment: 1-800-2ABBVIE (1-800-222-2843)
  • Copay card: May reduce costs to $10/month for eligible commercially insured patients
  • Income-based assistance: Available for uninsured/underinsured patients

New York State Programs

Medicaid: Covers Rinvoq with prior authorization Essential Plan: Low-cost option for those earning up to 200% of federal poverty level EPIC: Prescription assistance for Medicare beneficiaries in New York

How Counterforce Health Helps

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis—whether it's step therapy, medical necessity, or formulary status—and drafts point-by-point responses aligned to your plan's own rules, pulling the right medical citations and clinical evidence to support your case.

FAQ

How long does BCBS prior authorization take for Rinvoq in New York? Standard review takes 7-14 business days. Expedited review (with physician attestation) takes 72 hours.

What if Rinvoq isn't on my BCBS formulary? You can request a formulary exception through the same PA process. Include documentation of why formulary alternatives aren't appropriate.

Can I appeal if I've failed step therapy outside New York? Yes, but you'll need complete medical records from your previous providers documenting the failed treatments and reasons for discontinuation.

Does step therapy apply if I have contraindications to TNF inhibitors? No, step therapy can be bypassed with proper documentation of contraindications, allergies, or previous serious adverse reactions.

What's the success rate for Rinvoq appeals in New York? While specific statistics aren't published, New York's external appeal process has historically favored patients when proper medical evidence is provided, particularly for FDA-approved indications.

Can I use GoodRx or other discount programs for Rinvoq? Discount programs typically don't work for specialty medications. Focus on manufacturer assistance programs and insurance coverage instead.

What happens if my appeal is denied at every level? For Medicare plans, additional federal appeal levels are available. For commercial plans, you may have options through state insurance commissioners or legal consultation.

How often do I need to renew Rinvoq authorization? Most BCBS plans require annual reauthorization with documentation of continued clinical benefit and appropriate monitoring.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about treatment decisions. Insurance policies and procedures change frequently—verify current requirements with your specific plan. For personalized help with complex denials and appeals, consider working with specialists like Counterforce Health who can analyze your specific situation and craft targeted responses to insurance barriers.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.