Prior Authorization Criteria Update for Rinvoq and Cibinqo

June 13, 2022

HHSC updated the clinical prior authorization criteria for Rinvoq and Cibinqo within the Cytokine and CAM Antagonists clinical prior authorization criteria guide (PDF) to reflect the recent recommendations from the Texas Drug Utilization Review Board and the recent U.S. Food and Drug Administration (FDA) approved indications.

The following has been updated for Rinvoq:

  • Updated systemic therapy list for treatment of atopic dermatitis to include oral immunomodulators and oral glucocorticoids
  • Added Rinvoq ER 30 mg Tablets (GCN 51719) and Rinvoq ER 45 mg Tablet (GCN 52085) and added coverage for the diagnosis of ankylosing spondylitis. 
  • Added clarification about prior therapy criteria for clients with atopic dermatitis. The duration of treatment necessary for prior therapy should be 30 continuous days in the last 90 days. However, for a prior authorization renewal, the requirement for 30-days of prior therapy is not necessary.

The following has been updated for Cibingo:

  • Added clarification about prior therapy criteria for clients with atopic dermatitis. The duration of treatment necessary for prior therapy should be 30 continuous days in the last 90 days. However, for a prior authorization renewal, the requirement for 30-days of prior therapy is not necessary.
  • HHSC will notify pharmacies and prescribing providers when HHSC requires the updated Cytokine and CAM Antagonists clinical prior authorization criteria for fee-for-service.

HHSC will notify pharmacies and prescribing providers when HHSC requires the updated Cytokine and CAM Antagonists clinical prior authorization criteria for fee-for-service.

For MCOs, Cytokine and CAM Antagonists is optional.  The Pharmacy Clinical Prior Authorization Assistance Chart shows each MCO's prior authorization and how those authorizations relate to those used for processing fee-for-service Medicaid claims.  This chart is updated quarterly.  Providers can also refer to the MCO Resources for links to each MCO's list of clinical prior authorizations.