By Counterforce Health Team in Rinvoq (upadacitinib) —

How to Get Rinvoq (upadacitinib) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Guide to Prior Authorization, Appeals, and State Protections

Answer Box: Getting Rinvoq Covered in Pennsylvania

Blue Cross Blue Shield Pennsylvania requires prior authorization for Rinvoq (upadacitinib) with step therapy requirements. Your fastest path to approval: 1) Have your doctor submit PA documentation showing failed conventional DMARDs or TNF inhibitors, 2) Include clinical rationale and lab results, 3) Use specialty pharmacy routing. If denied, Pennsylvania's new external review program overturns ~50% of denials. Start today: Call your Blue Cross member services to confirm your specific formulary tier and PA requirements.

Table of Contents

  1. Why Pennsylvania State Rules Matter
  2. Blue Cross Blue Shield PA Requirements
  3. Turnaround Standards and Timelines
  4. Step Therapy Protections and Overrides
  5. Appeals Playbook for Pennsylvania
  6. Pennsylvania's External Review Program
  7. Continuity of Care Protections
  8. Practical Scripts and Templates
  9. When to Escalate to State Regulators
  10. FAQ: Common Questions

Why Pennsylvania State Rules Matter

Pennsylvania has strengthened its health insurance oversight significantly, creating new protections that work alongside your Blue Cross Blue Shield plan policies. The state's Independent External Review Program, launched in January 2024, has already overturned approximately 50% of insurance denials in its first year.

These state protections apply to most commercial Blue Cross plans in Pennsylvania, including Highmark Blue Shield (western PA) and Independence Blue Cross (Philadelphia region). However, self-funded employer plans governed by ERISA may have different rules - check with your HR department if you're unsure about your plan type.

Pennsylvania's regulations also include specific step therapy protections and continuity of care requirements that can help you maintain access to Rinvoq during plan changes or provider network updates.

Blue Cross Blue Shield PA Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Member portal or provider portal Highmark PA List
Step Therapy Must try conventional DMARDs, then TNF inhibitors first Plan formulary documents Independence Blue Cross Formulary
Specialty Pharmacy Must use contracted specialty pharmacy network Plan pharmacy benefits Plan documents
Formulary Tier Typically Tier 4-5 specialty drug Annual formulary Plan-specific formulary

Medical Necessity Criteria

For rheumatoid arthritis and psoriatic arthritis, Blue Cross Blue Shield Pennsylvania typically requires:

  • Diagnosis confirmation with appropriate ICD-10 codes
  • Failed conventional therapy: Methotrexate or other conventional DMARDs for adequate duration
  • Failed biologic therapy: At least one TNF inhibitor (adalimumab, etanercept, infliximab) unless contraindicated
  • Clinical documentation: Disease activity scores, inflammatory markers, functional assessment
  • Safety screening: TB testing, hepatitis screening, CBC, liver function tests

For atopic dermatitis, requirements include failed topical therapies and, often, failed dupilumab (Dupixent) unless contraindicated.

Turnaround Standards and Timelines

Pennsylvania Blue Cross Blue Shield plans must follow specific response timeframes:

Standard Prior Authorization

  • Timeline: 15 calendar days from receipt of complete request
  • Submission: Electronic submissions through provider portals process faster
  • Required documents: PA form, clinical notes, lab results, prior therapy documentation

Urgent/Expedited Requests

  • Timeline: 72 hours for urgent medical situations
  • Criteria: Serious threat to health if treatment is delayed
  • Documentation: Provider attestation of urgency required

Renewal Timelines

  • Annual reviews: Most specialty drugs require yearly reauthorization
  • Continuation: Submit renewal 30-60 days before expiration
  • Stability documentation: Demonstrate ongoing medical necessity and treatment response
Tip: Electronic submissions through Availity (Highmark) or member-specific portals typically process faster than fax submissions.

Step Therapy Protections and Overrides

Pennsylvania law provides several pathways to override step therapy requirements:

Medical Exception Criteria

Step therapy exceptions must be granted within 72 hours if:

  • The required drug is contraindicated for your medical condition
  • You have previously tried and failed the step therapy drug
  • The drug is expected to be ineffective based on your medical history
  • You are already stable on a different medication
  • The step therapy drug is not in your best interest

Documentation for Overrides

Your provider should include:

  • Clinical contraindications: Specific medical reasons why first-line drugs won't work
  • Prior treatment history: Detailed records of previous failures or adverse reactions
  • Therapeutic drug monitoring: Lab results showing inadequate drug levels or anti-drug antibodies
  • Guideline support: References to ACR/NPF guidelines supporting biologic use in your condition

For psoriatic arthritis specifically, clinical guidelines recommend biologics as first-line treatment, which can support exception requests when step therapy protocols require conventional DMARDs first.

Appeals Playbook for Pennsylvania

Internal Appeal Process

Level 1: Standard Internal Appeal

  • Filing deadline: 180 days from denial date
  • Decision timeline: 30 days for standard, 72 hours for urgent
  • Required documents:
    • Written appeal request with member ID
    • Copy of denial letter
    • Supporting clinical documentation
    • Provider letter explaining medical necessity
  • Submission: Use member appeal forms available on plan website

Required Documentation Checklist

  • Complete medical records related to your condition
  • Documentation of failed prior therapies with dates, doses, and reasons for discontinuation
  • Current lab results and disease activity measures
  • Provider letter explaining why Rinvoq is medically necessary
  • Relevant clinical guidelines or studies supporting treatment
  • Any therapeutic drug monitoring results
From our advocates: "We've seen the strongest appeals include specific lab values showing disease activity and detailed documentation of why each prior therapy failed - whether due to lack of efficacy, intolerance, or contraindications. Generic statements like 'patient failed methotrexate' are much weaker than 'patient discontinued methotrexate after 6 months at 25mg weekly due to persistent elevated liver enzymes (ALT 89 U/L) despite dose reduction.'"

Pennsylvania's External Review Program

If your internal appeal is denied, Pennsylvania offers one of the strongest external review programs in the country.

Key Features

  • Success rate: Approximately 50% of denials overturned in 2024
  • Filing deadline: 4 months from final internal denial
  • Decision timeline: 45 days standard, 72 hours expedited
  • Cost: Free to patients
  • Binding decision: Insurers must comply immediately

How to File

  1. Obtain final denial: Complete internal appeal process first
  2. Submit request: Online at pa.gov external review portal or by mail
  3. Include documentation: All medical records, provider letters, clinical studies
  4. Additional evidence: You have 15 days after assignment to submit extra supporting information

What Happens Next

  • Independent review organization (IRO) reviews your case
  • Panel of physicians evaluates medical necessity
  • If approved, insurer must provide immediate coverage, including retroactive coverage for out-of-pocket costs during appeal

When Counterforce Health helps patients navigate these external reviews, we focus on assembling comprehensive clinical evidence that directly addresses the specific denial reasons, significantly improving success rates in Pennsylvania's favorable review environment.

Continuity of Care Protections

Pennsylvania law requires Blue Cross plans to provide continuity of care during transitions:

Transition Protections

  • 60-day continuation: If your provider leaves the network or you switch plans
  • Ongoing treatment: Covers specialty drug therapy already in progress
  • Extension possible: Can be extended if clinically appropriate
  • Provider cooperation: Your doctor must agree to follow new plan's requirements

How to Request

  1. Contact member services immediately upon notification of provider/plan change
  2. Provide documentation of ongoing Rinvoq therapy
  3. Coordinate between old provider, new plan, and specialty pharmacy
  4. Request extension if 60 days isn't sufficient for safe transition

Practical Scripts and Templates

Patient Phone Script for Blue Cross Member Services

"Hi, I'm calling about prior authorization for Rinvoq, generic name upadacitinib, for [your condition]. My doctor wants to prescribe this, but I need to understand the PA requirements. Can you tell me:

  • What step therapy requirements apply to my specific plan?
  • What documentation does my doctor need to submit?
  • How long does the PA process typically take?
  • Is there an expedited process if my condition is urgent?"

Provider Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for [patient name] regarding Rinvoq denial. The patient has failed [specific prior therapies] with documented [specific reasons - lab values, adverse events, lack of efficacy]. Current disease activity is [specific measures]. Rinvoq is medically necessary because [clinical rationale]. When can we schedule this review?"

Appeal Letter Template Opening

"I am formally appealing the denial of Rinvoq (upadacitinib) for [patient name], member ID [number], dated [denial date]. This medication is medically necessary for [specific diagnosis] based on [clinical evidence]. The patient has satisfied step therapy requirements by [specific prior treatments and outcomes]..."

When to Escalate to State Regulators

Contact the Pennsylvania Insurance Department if:

  • Your insurer violates state timeline requirements
  • Step therapy exceptions are inappropriately denied
  • External review decisions aren't implemented
  • You need help navigating the appeals process

Pennsylvania Insurance Department Consumer Services

The Pennsylvania Health Law Project also provides free assistance with complex appeals, especially for low-income individuals.

FAQ: Common Questions

How long does Blue Cross Blue Shield PA take in Pennsylvania? Standard PA decisions are made within 15 days, urgent requests within 72 hours. Electronic submissions typically process faster than fax submissions.

What if Rinvoq is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. The same appeal process applies.

Can I request an expedited appeal? Yes, if your health could be seriously harmed by waiting. Both internal appeals and external reviews offer expedited timelines (72 hours).

Does step therapy apply if I failed therapies outside Pennsylvania? Yes, prior treatment history from other states counts toward step therapy requirements. Ensure your new provider has complete medical records.

What happens if I switch Blue Cross plans mid-treatment? Pennsylvania's continuity of care law provides 60-day protection for ongoing specialty drug therapy during plan transitions.

How much does Rinvoq cost with Blue Cross coverage? Costs vary by plan tier and deductible. Check with member services for your specific copay. AbbVie offers copay assistance programs that may reduce out-of-pocket costs.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, pulling the right clinical evidence and regulatory citations to support your case.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for the most current coverage information. Coverage policies can change, and individual circumstances may affect eligibility.

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