By Counterforce Health Team in Uptravi (selexipag) —

Do You Qualify for Uptravi (selexipag) Coverage by Blue Cross Blue Shield in Florida? Decision Tree & Next Steps

Quick Answer: Your Path to Uptravi Coverage in Florida

You likely qualify for Uptravi (selexipag) coverage through Blue Cross Blue Shield of Florida if you have confirmed WHO Group 1 pulmonary arterial hypertension (PAH), functional class II-IV symptoms, and have tried at least two other PAH medications without success. The fastest approval path requires submitting prior authorization with right heart catheterization results, documented therapy failures, and specialist prescription. Start by calling the number on your member ID card to verify your plan's formulary tier and required specialty pharmacy. Most approvals take 72 hours with complete documentation.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If You're "Likely Eligible"
  4. If You're "Possibly Eligible"
  5. If You're "Not Yet Eligible"
  6. If Your Request Gets Denied
  7. Coverage Requirements at a Glance
  8. Appeals Playbook for Florida Blue
  9. Frequently Asked Questions

How to Use This Decision Tree

This guide helps patients and clinicians navigate Blue Cross Blue Shield of Florida's requirements for Uptravi (selexipag), an oral medication that treats pulmonary arterial hypertension by delaying disease progression and reducing hospitalization risk.

Start here: Answer the questions in the eligibility triage below. Each path leads to specific next steps, required documentation, and realistic timelines for approval in Florida.

Note: Blue Cross Blue Shield operates as 33 independent plans. This guide focuses on Florida Blue (Blue Cross Blue Shield of Florida), which covers about 36% of Florida's insurance market. Requirements may vary slightly for other Blues or self-funded employer plans.

Eligibility Triage: Do You Qualify?

Work through these questions with your healthcare team:

✅ Question 1: Do you have confirmed WHO Group 1 PAH?

  • Right heart catheterization showing mean pulmonary artery pressure ≥20 mmHg
  • Pulmonary capillary wedge pressure ≤15 mmHg
  • Pulmonary vascular resistance >3 Wood units
  • ICD-10 codes: I27.0, I27.20-I27.29

✅ Question 2: What's your functional status?

  • WHO Functional Class II, III, or IV symptoms
  • 6-minute walk test results documented
  • Current symptoms limiting daily activities

✅ Question 3: Have you tried other PAH medications?

  • Required step therapy: At least 60 days each of:
    • PDE-5 inhibitor (sildenafil/Revatio, tadalafil/Adcirca)
    • Endothelin receptor antagonist (ambrisentan/Letairis, bosentan/Tracleer, macitentan/Opsumit)
  • Document inadequate response, intolerance, or contraindications
  • Riociguat (Adempas) may substitute for one requirement

✅ Question 4: Is your prescriber qualified?

  • Pulmonologist, cardiologist, or PAH specialist
  • Experience managing pulmonary hypertension

If You're "Likely Eligible"

You answered "yes" to all four questions above. Here's your document checklist and submission path:

Document Checklist for Prior Authorization

Required Document What to Include Where to Get It
PA Request Form Complete Florida Blue provider portal form Your doctor's office
Right Heart Catheterization Hemodynamic measurements, date performed Cardiology records
Functional Assessment WHO class, 6-minute walk distance, symptoms Pulmonology notes
Prior Therapy History Medications tried, doses, duration, failure reasons Pharmacy records, chart notes
Current Treatment Plan Uptravi dosing strategy, monitoring plan Prescriber letter

Submission Path

  1. Verify coverage - Call member services (number on your ID card) to confirm:
    • Your plan covers Uptravi (formulary tier)
    • Required specialty pharmacy (often Prime Therapeutics affiliates)
    • Your doctor is in-network
  2. Submit PA request - Your doctor submits via:
    • Florida Blue provider portal (preferred)
    • Fax: (verify current number with provider services)
    • Mail with required forms and documentation
  3. Track timeline - Standard review: 72 hours for approval/denial letter

Counterforce Health Can Help

When dealing with complex prior authorization requirements like those for Uptravi, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify exactly why coverage was refused, then drafts point-by-point rebuttals using FDA labeling, peer-reviewed studies, and specialty guidelines that align with your insurer's own rules.

If You're "Possibly Eligible"

You answered "yes" to questions 1-2 but need more documentation for questions 3-4. Here's what to track and request:

Tests to Request

  • Complete step therapy documentation: Gather pharmacy records showing 60+ day trials of required medications
  • Specialist referral: If your current doctor isn't a pulmonologist/cardiologist, request referral
  • Updated functional testing: Recent 6-minute walk test, WHO functional class assessment

Timeline to Re-apply

  • Gather missing docs: 2-4 weeks
  • Complete step therapy: 60-120 days (if ongoing)
  • Specialist appointment: 2-8 weeks in Florida

What to Track

Keep a medication diary documenting:

  • Current symptoms and limitations
  • Side effects from previous PAH medications
  • Hospitalizations or emergency visits
  • Changes in exercise tolerance

If You're "Not Yet Eligible"

You don't meet basic diagnostic or step therapy requirements. Here are alternatives to discuss with your healthcare team:

Alternatives to Consider

  1. Complete required step therapy with PDE-5 inhibitors and ERAs
  2. Optimize current PAH medications before adding Uptravi
  3. Consider other prostacyclin pathway drugs (treprostinil, epoprostenol)
  4. Participate in clinical trials if available in Florida

Prepare for Exception Requests

Document any contraindications or intolerances to required step therapy medications:

  • Severe hypotension with PDE-5 inhibitors
  • Liver toxicity with ERAs
  • Drug interactions with current medications

If Your Request Gets Denied

Don't give up. Appeals success rates for specialty drugs range 40-60% with strong clinical evidence. Here's your appeal path:

Level 1: Internal Appeal

  • Timeline: File within 60 days of denial
  • Process: Submit via Florida Blue member portal with additional evidence
  • Decision: 30 days (standard) or 72 hours (expedited if urgent)

Level 2: Peer-to-Peer Review (Optional)

  • Timeline: Request within 72 hours of internal denial
  • Process: Your doctor discusses case directly with Florida Blue medical director
  • Contact: Call number provided in denial letter

Level 3: External Review

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing Florida Blue PA info
Formulary Tier Check your plan's medication list Member portal or call member services
Step Therapy Try 2+ other PAH drugs first Plan policy documents
Specialty Pharmacy Must use designated pharmacy Member services can provide list
Quantity Limits 60-day supply typical Listed in formulary guides
Diagnosis Codes WHO Group 1 PAH (I27.0) Medical records

Appeals Playbook for Florida Blue

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
Insufficient PAH proof Submit complete hemodynamic data Right heart cath results, echo
Missing step therapy Document prior medication trials Pharmacy records, failure notes
Non-preferred drug Request formulary exception Medical necessity letter
Quantity exceeded Justify dosing requirements FDA labeling, titration plan

Scripts for Success

Patient phone script for member services: "I'm calling about prior authorization for Uptravi, NDC 50458-582-60. Can you tell me my plan's formulary tier, required specialty pharmacy, and current PA status? My member ID is [number]."

Clinic staff script for peer-to-peer: "We're requesting peer-to-peer review for [patient name], DOB [date], member ID [number]. The denial was for Uptravi for WHO Group 1 PAH. Dr. [name] is available [days/times] to discuss clinical rationale."

Frequently Asked Questions

How long does Florida Blue prior authorization take? Standard review: 72 hours. Expedited (if urgent): 24 hours. Complex cases may take up to 14 days with additional information requests.

What if Uptravi isn't on my formulary? Request a formulary exception with medical necessity documentation. Success rates improve with specialist support and evidence of failed alternatives.

Can I get expedited review? Yes, if delay would seriously jeopardize your health. Your doctor must attest to urgency in the PA request.

Does step therapy apply if I tried medications in another state? Yes, pharmacy records from any state count toward step therapy requirements. Gather all documentation from previous providers.

What's the cost without insurance approval? Retail prices range $9,000-$25,000 monthly. Janssen's Uptravi Access & Support offers copay assistance and patient support programs.

How do I track my appeal status? Use Florida Blue's member portal or call the member services number on your ID card. Keep all correspondence and reference numbers.

When should I contact Florida regulators? If Florida Blue doesn't follow required timelines, denies without proper review, or you suspect discriminatory practices. Contact the Florida Office of Insurance Regulation at 1-877-693-5236.

What happens during external review? An independent medical expert reviews your case using current medical standards. If they overturn the denial, Florida Blue must cover the medication. This process is free and binding.

For complex cases involving multiple denials or appeals, Counterforce Health provides specialized support in crafting evidence-backed appeals that address insurers' specific denial reasons and align with their own policy requirements.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage policies change frequently; verify current requirements with your insurer and healthcare team.

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