RINVOQ Health Insurance Denial

• Received a RINVOQ Health Insurance Denial? Contact Us
• What is RINVOQ?
• How Does RINVOQ Work? 
• What is the Dosage Form and Who Can Take RINVOQ?
• How Much Does RINVOQ Cost?
• Is There a Generic Drug for RINVOQ?
• Do Insurance Companies Cover RINVOQ As a Treatment for Inflammatory Conditions?
• Understanding Medically Necessary, Medically Beneficial, Experimental, or Investigational 
• How Do Insurance Companies Evaluate RINVOQ Coverage Requests?
• What Duty Do Insurance Companies Have to Members Submitting Claims?
• Contact the Law Offices of Scott Glovsky if You Receive a RINVOQ Health Insurance Denial

Received a RINVOQ Health Insurance Denial? Contact Us

RINVOQ (Upadacitinib) has received numerous FDA approvals for a variety of conditions including autoimmune disorders. In August 2019, RINVOQ received FDA approval for the treatment of severe rheumatoid arthritis, and in December 2021, RINVOQ was approved for the treatment of psoriatic arthritis. In January 2022, RINVOQ was approved for the treatment of atopic dermatitis. In April 2022, it was approved for ankylosing spondylitis, and in October 2022, RINVOQ was approved for the treatment of non-radiographic axial spondyloarthritis. 

In March 2022, RINVOQ garnered FDA approval for the treatment of ulcerative colitis. In May 2023, it received approval for Crohn’s disease, and most recently, in April 2025, RINVOQ was approved to treat giant cell arteritis.  If your doctor believes RINVOQ will improve your health outcomes, yet your insurance company has issued a claim denial, it is time to contact the Law Offices of Scott Glovsky.

What is RINVOQ?

RINVOQ is a prescription medication in the form of a once-daily pill used to treat certain inflammatory conditions, particularly those involving the immune system. RINVOQ is a JAK inhibitor that works by blocking a protein that plays a major role in inflammation. RINVOQ is often used when other treatments have not been effective. 

RINVOQ treats moderate to severe rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, giant cell arthritis, moderate to severe ulcerative colitis, and moderate to severe Crohn’s disease. It is also used to treat moderate to severe atopic dermatitis (eczema) in adults and adolescents 12 years and older. You can read more about RINVOQ here.  

How Does RINVOQ Work? 

RINVOQ is a Janus kinase (JAK) inhibitor. JAK enzymes are involved in the pathways leading to inflammation. By blocking these enzymes, RINVOQ helps reduce inflammation throughout the body. 

What is the Dosage Form and Who Can Take RINVOQ?

RINVOQ is available as an extended-release tablet and an oral solution. RINVOQ is usually prescribed when other treatments have not been successful; it is not considered a first-line treatment because it can increase the risk of serious infections, blood clots, and certain cancers. 

If you are taking RINVOQ you should avoid grapefruit and grapefruit juices because they can slow down the breakdown of the drug in your body, leading to high levels in your system, and increasing the risk of adverse side effects.    

How Much Does RINVOQ Cost?

The list price of RINVOQ for a 30-day supply is $6,752.77 as of January 2025. If you have commercial insurance through your employer, you may be eligible to pay $0 per month with the RINVOQ Complete Savings Card. If you have Medicaid, your co-pay for RINVOQ could be as little as $10.40 or less. If you are enrolled in Medicare Part D, you may pay between $0 and $2,000 for RINVOQ, depending on your coverage phase and any coverage gaps. If you are uninsured or cannot afford your medication, AbbVie may be able to help with its Complete Savings Card.   

Is There a Generic Drug for RINVOQ?

RINVOQ currently has no generic counterpart drug available because it is still under patent protection. Patents on drugs like RINVOQ can prevent the development and marketing of generics. RINVOQ’s patents were eligible for challenge beginning in August 2023; however, the earliest projected generic entry date is October 2036. 

While there are no generic drugs to RINVOQ, there are other similar drugs that are JAK inhibitors like RINVOQ. These drugs include:

• Xeljanz (tofacitinib) approved for rheumatoid arthritis and other inflammatory conditions.
• Cibingo (abrocitinib) approved for moderate-to-severe atopic dermatitis.
• Olumiant (baricitinib) approved for rheumatoid arthritis and COVID-19
• Jakafi (ruxolitinib), used for certain blood cancers.
• Humira (adalimumab), a TNF inhibitor used for inflammatory conditions, including eczema and rheumatoid arthritis.
• Dupixent (dupilumab), an injection used to treat inflammatory conditions like eczema. 
• Simponi (golimumab), a monoclonal antibody used for arthritis and ulcerative colitis

Do Insurance Companies Cover RINVOQ As a Treatment for Inflammatory Conditions?

If you have received a RINVOQ health insurance denial, you have the right to appeal; however, before you appeal, you need to know what type of health insurance you have. ERISA (Employment Retirement Income Security Act of 1974) plans are provided by most private employers, with the following potential exceptions: 

• Business plans that only cover business owners
• Individual and family plans through Covered California
• Government employee plans
• Religious organization plans
• Individual and family plans purchased through private insurance companies like Blue Shield of California or Anthem Blue Cross

If you are covered under an ERISA plan, you should file an appeal after speaking to an attorney, as these plans require you to exhaust your administrative remedies. If you have a non-ERISA plan, you have options, and you should discuss the situation with your attorney to determine the best path forward. 

Government health insurance programs, such as Medicaid and Medicare, will likely provide coverage for RINVOQ as a treatment for your specific condition, which falls under the umbrella of autoimmune diseases. Medicaid provides health insurance for low-income individuals and families who would otherwise be unable to afford coverage. Coverage for RINVOQ could be free or very low-cost through Medicaid.  

Medicare is a federal health insurance program for those 65 and older. Coverage may be through a Medicare Advantage Plan (Part C) or a Supplemental Plan (Part D). Patients are required to enroll separately from their Medicare plan for prescription drug coverage. While Medicare will likely cover RINVOQ, there may be a co-pay involved, depending on the specific plan.    

If you have commercial private health insurance, such as Anthem, Kaiser Permanente, Blue Shield, a Medi-Cal Managed Care Plan, Healthnet, UnitedHealthcare, or Aetna, there may be different coverage standards. While many private insurers will cover RINVOQ as a treatment for the conditions listed above, coverage requirements will vary from one insurer to another. Your coverage may depend on whether the insurer deems the drug medically necessary, decides it is not medically necessary, or is experimental or investigational.  

Understanding Medically Necessary, Medically Beneficial, Experimental, or Investigational 

The process for obtaining approval for a more expensive drug typically involves prior authorization, which requires the insurer to determine that the drug is medically necessary. A drug can be medically beneficial for a patient, yet an insurer could declare it not medically necessary. This is because there are usually alternative (less expensive) drugs that can treat the same conditions. Step therapy is a form of prior authorization that requires patients to try a less expensive drug for their symptoms, typically for a period of 60 days. In some cases, two alternative drugs may be required before the name-brand drug could be approved.

The state of California has specific exemptions regarding step therapy; however, the process for avoiding step therapy can be complex. Step therapy can prevent patients from getting approval for the name-brand drug recommended by their doctors. Insurers may also deem a drug as experimental or investigational. This can occur when a drug is relatively new or when a drug is being prescribed off-label by a physician. 

Drugs are commonly prescribed for off-label use, which means that the FDA has not specifically approved the drug for this use, the prescription strength differs from the FDA's specifications for the drug, or it is being used for a demographic not specifically approved by the FDA. Yet, when a drug is prescribed off-label (by some statistics, off-label prescriptions make up from 21 to 46 percent of all drug prescriptions), an insurer may deem it experimental or investigational possibly to avoid paying for it. The guidelines that determine whether a drug is medically necessary, experimental, or investigational are extremely subjective, which can make it frustrating for patients.   

How Do Insurance Companies Evaluate RINVOQ Coverage Requests?

Insurance companies have their own pharmacists and other healthcare practitioners research newly approved drugs and develop internal clinical policies, and then a group of external doctors votes on those policies. Unfortunately, these votes may be swayed by financial incentives or job offers from the insurance companies, leading to overly restrictive policies. 

What Duty Do Insurance Companies Have to Members Submitting Claims?

When a member submits a claim, the insurance companies must:

• Thoroughly investigate the claim
• Fully inquire into all the reasons that support care requests.
• Promptly respond to claim requests
• Appoint and employ qualified medical professionals to make claim review decisions.

Contact the Law Offices of Scott Glovsky if You Receive a RINVOQ Health Insurance Denial

Receiving a RINVOQ health insurance denial can be frustrating and demoralizing. The Law Offices of Scott Glovsky has represented injured consumers and victims of wrongful business practices for over 25 years. Our firm focuses on health insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related litigation. We work hard to obtain justice for our clients while holding wrongdoers accountable.