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Limited coverage criteria – upadacitinib for Crohn's disease

Last updated on March 27, 2025

 

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Generic name

upadacitinib

Strength & form

15 mg/30 mg/45 mg, extended-release tablet

Special Authority criteria

Approval period

Initial

Moderately to severely active Crohn's disease

For the treatment of adult patients with moderately to severely active Crohn's disease when ALL of the following criteria are met:

Special Authority request is submitted by a gastroenterologist

AND

Patient has a Harvey-Bradshaw Index of 8 or higher1

AND

Patient has had an unsuccessful trial of steroids for their current Crohn’s disease activity. The trial must include a steroid dose equivalent to oral prednisone 40 mg or more daily taken for at least 14 consecutive days. Unsuccessful trial is defined as one of the following:

  • Inadequate response to steroids2
  • Adequate response while on steroids, but with recurrence of disease following tapering or withdrawal of steroids3
  • Inability to complete steroid course due to intolerance or contraindication4

istulizing Crohn's disease

For the treatment of adult patients with active fistulizing Crohn's disease when ALL of the following criteria are met:

Special Authority request is submitted by a gastroenterologist

AND

Patient has had an inadequate response or intolerance to a course of ciprofloxacin for a minimum of 3 consecutive weeks at maximally tolerated doses, or

  • Has a contraindication to ciprofloxacin

16 weeks

Renewal

Moderately to severely active Crohn’s disease

For the continued treatment of adult patients with moderately to severely active Crohn's disease when ALL of the following criteria are met:

Special Authority request is submitted by a gastroenterologist

AND

Patient has a Harvey-Bradshaw Index decrease of at least 4 points, or

  • Total Harvey-Bradshaw Index must be 5 points or less

Fistulizing Crohn's disease

For the continued treatment of adult patients with active fistulizing Crohn's disease when ALL of the following criteria are met:

Special Authority request is submitted by a gastroenterologist

AND

Patient has demonstrated an improvement in the number of and/or severity of fistulae

  

 

Practitioner exemptions

  • None

Special notes

  • 1Moderately to severely active Crohn's disease as defined by a Harvey-Bradshaw Index of 8 or higher following completion of a course of steroids (equivalent to oral prednisone 40 mg or more daily for a minimum of 14 consecutive days)
  • 2Inadequate response to steroids is defined as displaying a lack of symptomatic response to therapy
  • 3Steroid dependence is defined as: unable to withdraw oral corticosteroid within 3 months of initiation without a recurrence of symptoms; a symptomatic relapse within 3 months of stopping; or the need for 2 or more courses of corticosteroids within 1 year
  • 4The patient’s contraindication to steroid therapy or intolerance/adverse effects to a course of steroids (equivalent to oral prednisone 40 mg or more daily for a minimum of 14 consecutive days) must be specified in the Special Authority request for upadacitinib
  • For initial requests in patients who are able to complete a 14-day course of steroids, the patient’s Harvey-Bradshaw Index must be completed after a course of at least 14 consecutive days of steroid therapy and prior to their initiation of upadacitinib therapy
  • For initial requests in patients who have had prior surgery or surgeries (such as ostomy, pouch, or prior resection), the patient's usual number of liquid bowel movements and Harvey-Bradshaw Index worksheet must be submitted with each Special Authority coverage request for upadacitinib
  • PharmaCare coverage will not be provided for upadacitinib in combination with biologic drugs or other janus kinase (JAK)-inhibitors for the treatment of Crohn’s disease
  • PharmaCare covers a maximum of 30 days' supply per fill of upadacitinib
  • Additional information needed in requests is detailed on the forms linked below

Special Authority request form(s)