Rinvoq Prior Authorization Resources

Find the right PA form for your patient's payer, get the ICD-10 codes you need, and download appeal templates — all in one place.

Last verified: May 08, 2026

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated May 08, 2026
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated May 08, 2026
California - Uniform Prior Authorization FormCalifornia · Updated May 16, 2026
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc. · Updated May 08, 2026
Cigna - General Medication Prior Authorization FormCigna Corporation · Updated May 08, 2026
Colorado - Uniform Prior Authorization FormColorado · Updated May 16, 2026

ICD-10 codes for Rinvoq Prior Authorizations

M06.9Rheumatoid arthritis, unspecified
M05.9Rheumatoid arthritis with rheumatoid factor, unspecified
L40.50Arthropathic psoriasis, unspecified
L40.51Distal interphalangeal psoriatic arthropathy
L20.9Atopic dermatitis, unspecified
L20.8Other atopic dermatitis
K51.90Ulcerative colitis, unspecified, without complications
K51.9Ulcerative colitis, unspecified
K50.90Crohn's disease, unspecified, without complications
K50.9Crohn's disease, unspecified
M45.9Ankylosing spondylitis of unspecified sites in spine
M45.0Ankylosing spondylitis of multiple sites in spine
M45.1Ankylosing spondylitis of occipito-atlanto-axial region
M45.7Ankylosing spondylitis of lumbosacral region
M08.3Juvenile rheumatoid polyarthritis (seronegative)
M08.9Juvenile arthritis, unspecified
M08.40Pauciarticular juvenile rheumatoid arthritis, unspecified site
M31.5Giant cell arteritis with polymyalgia rheumatica

Appeal Templates

If the payer denies coverage, these templates help you build a stronger appeal.
Appeal Letter Sample TemplateAppeal denied PA requests. Customizable template with clinical justification framework, denial responses, supporting evidence. Streamlines resubmission.
Formulary Exception Dermatology TemplateRequest formulary exceptions for AD. Dermatology-specific template: clinical criteria, disease severity, treatment history. For non-preferred tier placement.
Formulary Exception Gastroenterology TemplateRequest formulary exceptions for UC/CD. GI-specific template: clinical criteria, disease activity, TNFi failure documentation. Non-preferred tier placement.
Formulary Exception Rheumatology TemplateRequest formulary exceptions for RA/PsA/AS. Rheumatology template: clinical criteria, joint assessments, DMARD/TNFi failures. Non-preferred tier placement.
Letter Of Medical Necessity Sample TemplateCustomizable LON for PA submissions. Patient demographics, diagnosis, ICD-10 codes, clinical rationale, treatment history. Supports insurance approval.
PA Appeal Letter: Step-by-Step Guide [PDF]Step-by-step guide for writing PA appeal letters. Includes required elements, clinical justification tips, supporting documentation. Use with appeal letter template.
Formulary Exception: Step-by-Step Guide [PDF]Step-by-step guide for formulary exception requests. Includes required elements, clinical justification tips, cost-effectiveness rationale. Use with templates.
Tiering Exception: Step-by-Step Guide [PDF]Step-by-step guide for tiering exception requests. Includes required elements, cost comparison rationale, clinical equivalency justification. Use with template.
A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.

Brand Resources

Tiered Exception Letter Sample TemplateRequest lower copay tier for non-preferred formulary. Cost comparison, clinical equivalency, financial burden documentation. Reduces patient out-of-pocket costs.
HIPAA Authorization for Access Support [PDF]HIPAA authorization form for RINVOQ Complete access specialists. Enables patient support team to assist with PA, benefits verification, copay programs.
Gastro Pa Brochure DigitalPA support for UC/CD: submission guide, documentation checklist, denial reasons, appeals. Specialty-specific PA criteria and coding included.
LON Instructions: Step-by-Step Guide [PDF]Step-by-step guide for writing letters of medical necessity. Includes required elements, clinical justification tips, trial failure documentation. Use with LON template.
Rheum Pa Brochure Digital Ped SpPA support for pJIA (2+ years): submission workflows, age-appropriate documentation, growth considerations, specialty pharmacy coordination.
PA Checklist: RA, PsA, AS, nr-axSpA [PDF]PA documentation checklist for rheumatology indications. Lists required patient info, diagnosis codes, treatment history, DMARD/TNFi failures. Use before PA submission.
AD PA Brochure: Coverage Support Guide [PDF]Prior authorization support guide for AD patients. Includes common PA requirements, payer criteria, documentation tips, forms needed. Supports PA submission process.
AD PA Checklist: Required Documentation [PDF]PA documentation checklist for AD patients. Lists required patient info, diagnosis codes, treatment history, topical/systemic failures. Use before PA submission.

Support for Getting Your Patient on Rinvoq

Check coverage & formulary statusVerify PA requirements for your patient's plan.Find savings programsCopay cards, patient assistance, and more.Check medication interactionsScreen prescriptions for harmful drug combinations.