By Counterforce Health Team in Rinvoq (upadacitinib) —

How to Get Rinvoq (upadacitinib) Covered by Blue Cross Blue Shield in Washington: Forms, Appeals, and Success Strategies

Quick Answer: Getting Rinvoq Covered by Blue Cross Blue Shield in Washington

Rinvoq (upadacitinib) requires prior authorization from Blue Cross Blue Shield plans in Washington, with most plans mandating documented failure of TNF inhibitors first. Submit through the Availity portal (fastest: 1-3 days) or fax using Premera's pharmacy PA form. If denied, you have 180 days to appeal internally, then can request external review through Washington's Office of the Insurance Commissioner. Key success factors: detailed medical necessity letter, TNF failure documentation, and current safety labs.

First step today: Contact your prescriber to gather TNF inhibitor failure records and recent lab results (CBC, liver function) before submitting the PA request.

Table of Contents

Understanding Rinvoq Coverage in Washington

Rinvoq (upadacitinib) is an oral JAK inhibitor manufactured by AbbVie, approved for multiple autoimmune conditions including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, atopic dermatitis, ulcerative colitis, and Crohn's disease. In Washington state, the primary Blue Cross Blue Shield provider is Premera Blue Cross, with Regence BlueCross BlueShield serving some regions.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all indications Premera drugs requiring approval
Formulary Tier Preferred B3 tier (as of December 2024) Member portal or formulary PDF
Step Therapy TNF inhibitor failure required Plan-specific PA criteria
Quantity Limits 30-day supply typically PA approval letter
Specialist Required Rheumatologist, dermatologist, or GI specialist PA submission requirements

Prior Authorization Requirements

Blue Cross Blue Shield plans in Washington follow strict criteria for Rinvoq approval, varying slightly by specific condition but generally requiring:

Universal Requirements

  • Diagnosis confirmation: ICD-10 codes for approved conditions (e.g., M05-M06 for RA, L20 for atopic dermatitis)
  • Specialist oversight: Rheumatologist, dermatologist, allergist, immunologist, or gastroenterologist
  • Safety screening: Recent labs showing hemoglobin ≥8 g/dL, liver enzymes <3x upper normal limit
  • Infection screening: No active tuberculosis, hepatitis B risk assessment, up-to-date vaccinations

Condition-Specific Criteria

Rheumatoid Arthritis & Psoriatic Arthritis

  • Moderately to severely active disease
  • Documented failure, contraindication, or intolerance to at least one TNF inhibitor (adalimumab, etanercept, certolizumab)
  • Cannot be used with other biologics or targeted immunomodulators

Atopic Dermatitis

  • Moderate to severe disease inadequately controlled by topical therapies
  • Prior systemic therapy trial (may include TNF inhibitors depending on plan)

Ulcerative Colitis & Crohn's Disease

  • Moderately to severely active inflammatory bowel disease
  • TNF inhibitor failure required unless clinically inappropriate (updated Premera criteria clarify when TNF trial can be waived)
Note: Washington state law prohibits step therapy requiring multiple failures within the same drug class, so plans cannot mandate trying more than one TNF inhibitor.

Step-by-Step Approval Process

Step 1: Verify Coverage and Requirements

Who: Patient or clinic staff
Action: Log into Premera member portal to confirm current formulary status and PA requirements
Timeline: 5-10 minutes
Documentation: Save formulary page showing Rinvoq coverage tier

Step 2: Gather Required Documentation

Who: Prescriber and clinic staff
Documents needed:

  • Complete medical history with diagnosis codes
  • TNF inhibitor trial records (dates, duration, reason for discontinuation)
  • Recent lab results (CBC, comprehensive metabolic panel, liver function tests)
  • Current disease activity scores or symptom documentation
  • Specialist consultation notes

Step 3: Complete Prior Authorization Submission

Who: Prescriber
Method: Availity portal (recommended) or fax using Premera's pharmacy PA form
Timeline: 1-3 business days via portal, 3-5 days via fax
Required elements:

  • Patient demographics and insurance information
  • Prescriber details with NPI number
  • Clinical justification addressing specific PA criteria
  • Supporting documentation attached

Step 4: Track Status and Follow Up

Who: Clinic staff or patient
Action: Monitor submission status through Availity or call Premera member services
Timeline: Check within 48-72 hours of submission

Step 5: Receive Determination

Approval: Authorization typically granted for 12 months with quantity limits specified
Denial: Proceed to appeals process with detailed reasoning provided

Clinician Corner: When drafting the medical necessity letter, address each PA criterion explicitly. Include specific dates of TNF inhibitor trials, documented side effects or inadequate response, current disease activity measures, and how Rinvoq fits into the treatment plan. Reference FDA labeling and relevant clinical guidelines to strengthen the request.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient TNF inhibitor trial Document adequate trial duration and specific reason for failure Prescription records, clinic notes, patient-reported outcomes
Missing safety labs Submit recent comprehensive lab panel CBC, CMP, liver function tests within 3 months
Non-specialist prescriber Transfer prescription to appropriate specialist Rheumatology, dermatology, or GI consultation
Lack of medical necessity Strengthen clinical justification with guidelines Disease activity scores, functional assessments, quality of life measures
Quantity limit exceeded Justify dosing based on FDA labeling Weight-based calculations, specialist recommendations

Appeals Process for Washington Residents

Washington state provides robust appeal rights through a two-level internal process followed by external review options.

Internal Appeals Timeline

Appeal Level Deadline to File Decision Timeline How to Submit
Level 1 180 days from denial 30 days standard / 72 hours expedited Availity portal, mail, or fax
Level 2 60 days from Level 1 denial 30 days standard / 72 hours expedited Same methods as Level 1

Required Appeal Documents

  • Original denial letter
  • Updated medical necessity letter addressing denial reasons
  • Additional clinical evidence (new labs, specialist opinions)
  • Patient impact statement (optional but helpful)

When to Request Expedited Review

Mark your appeal "EXPEDITED" with physician certification if:

  • Delaying treatment could seriously jeopardize your health
  • You're experiencing worsening symptoms while awaiting decision
  • Standard timeline could result in permanent functional impairment

External Review with Independent Review Organization

If internal appeals are unsuccessful, Washington residents can request external review through the state's Independent Review Organization (IRO) process, regulated under RCW 48.43.535.

External Review Process

  1. Eligibility: Must exhaust internal appeals first (or they're deemed exhausted)
  2. Timeline: File within 120 days of final internal denial
  3. Cost: Free to patients; insurers pay IRO fees
  4. Decision: Binding on Blue Cross Blue Shield; must implement within 24 hours if overturned

How to Request External Review

Submit written request to Blue Cross Blue Shield at the address provided in your denial notice, including:

  • Patient identification and policy information
  • Description of denied service (Rinvoq for specific condition)
  • Statement requesting external review under Washington state law
  • All supporting medical documentation
  • Physician letter explaining medical necessity

Contact for assistance: Washington Office of the Insurance Commissioner at 1-800-562-6900 or visit insurancecommissioner.wa.gov.

From our advocates: We've seen external reviews succeed when families include peer-reviewed studies showing Rinvoq's effectiveness for their specific condition, especially when standard treatments have failed. The key is presenting a compelling medical story that goes beyond just meeting insurance criteria—show how this medication will meaningfully improve the patient's quality of life and long-term outcomes.

Cost-Saving Resources

While pursuing coverage approval, several programs can help reduce out-of-pocket costs:

Manufacturer Support

  • RINVOQ Complete: AbbVie's patient support program offering up to 2 years of free medication during appeals
  • Eligibility: Requires denial confirmation and active appeal submission every 180 days
  • Contact: Visit rinvoq.com/patient-support or call patient services

Alternative Funding

  • State pharmaceutical assistance programs: Check Washington state resources for specialty drug coverage
  • Nonprofit foundations: Organizations like the Patient Access Network Foundation may provide grants
  • Clinical trials: Ongoing studies may provide access to Rinvoq or similar medications

Interim Coverage Options

  • 30-day emergency supply: Many plans provide temporary coverage during appeals
  • Provider samples: Ask your prescriber about available samples
  • Bridge therapy: Temporary alternative treatments while awaiting approval

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Washington? Electronic submissions through Availity typically receive responses in 1-3 business days, while fax submissions take 3-5 days. Complex cases may require up to 14 days for review.

What if Rinvoq is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate. This requires detailed documentation of why formulary options won't work for your specific situation.

Can I request expedited review if my condition is worsening? Yes, both internal appeals and external reviews can be expedited if your physician certifies that standard timelines would jeopardize your health. Expedited decisions are typically made within 72 hours.

Does step therapy apply if I failed TNF inhibitors in another state? Yes, documented TNF inhibitor failures from any state count toward meeting step therapy requirements. Ensure you have complete records from your previous providers.

What happens if my appeal is denied at all levels? After exhausting internal and external appeals, you may consider legal consultation, especially for ERISA plans. You can also file a complaint with the Washington Office of the Insurance Commissioner if you believe the process was mishandled.

How often do I need to renew Rinvoq authorization? Most approvals are granted for 12 months, requiring reauthorization with updated clinical documentation showing continued medical necessity and positive treatment response.

Can I switch to a different Blue Cross Blue Shield plan during open enrollment? Yes, but check each plan's formulary and PA requirements, as they may vary. Current Rinvoq users may have grandfathering protections during plan transitions.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed strategies tailored to specific payer requirements. Our platform analyzes denial letters and drafts targeted rebuttals using the right clinical evidence and procedural requirements for each insurance company's unique criteria.

For additional support with your Rinvoq appeal or other specialty medication denials, Counterforce Health offers tools and guidance to strengthen your case and improve approval odds.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Appeal processes and requirements may change; verify current procedures with your insurer and state regulators.

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