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Prior Authorization Criteria Update for Rinvoq and Sibinqo

Last updated on

The Texas Health and Human Services Commission (HHSC) has updated the clinical prior authorization criteria for Rinvoq and Cibinqo within the Cytokine and CAM Antagonists clinical prior authorization. This update reflects recent recommendations from the HHSC Drug Utilization Review Board and indications approved by U.S. Food and Drug Administration.

Rinvoq

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 Tablets (GCN 52085) and added coverage for the diagnosis of ankylosing spondylitis.
  • Added clarification about prior therapy criteria for clients with atopic dermatitis. For initial prior authorization, the client must have received at least 30 continuous days of prior therapy treatment within the last 90 days. However, for a prior authorization renewal, there is no requirement for 30 continuous days of prior therapy treatment.

Cibinqo

The following has been updated for Cibingo:

  • Added clarification about prior therapy criteria for clients with atopic dermatitis. For initial prior authorization, the client must have received at least 30 continuous days of prior therapy treatment within the last 90 days. However, for a prior authorization renewal, there is no requirement for 30 continuous days of prior therapy treatment.
  • 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, the Cytokine and CAM Antagonists clinical prior authorization is optional. The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorization each MCO uses 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.

Contact vdp-formulary@hhsc.state.tx.us with comments or any questions.