By Counterforce Health Team in Uptravi (selexipag) —

Getting Uptravi (Selexipag) Covered by Cigna in North Carolina: Prior Authorization Guide, Appeals Process & Alternative Options

Answer Box: Quick Path to Uptravi (Selexipag) Coverage

To get Uptravi covered by Cigna in North Carolina: Your cardiologist or pulmonologist must submit prior authorization with WHO Group 1 PAH diagnosis via right heart catheterization, functional class documentation, and prior therapy trials. If denied, file internal appeal within 180 days, then external review through Smart NC (1-855-408-1212) within 120 days. Standard reviews take 72 hours; expedited reviews 24 hours for urgent cases.

Start today: Contact your prescriber to initiate prior authorization through Cigna's provider portal or by calling the precertification number on your insurance card.

Table of Contents

When Alternatives Make Sense

If Uptravi (selexipag) isn't immediately approved by Cigna, considering formulary alternatives may help you start PAH treatment sooner while pursuing an exception or appeal. This approach makes sense when:

  • Your condition requires immediate treatment and delays could worsen your prognosis
  • You haven't tried other prostacyclin pathway agents or combination therapies
  • Your provider determines that starting with a formulary drug could provide clinical benefit
  • You're willing to document the trial for future Uptravi authorization

However, alternatives aren't always appropriate. If you've already failed other PAH therapies or have specific contraindications, pursuing an exception for Uptravi may be your best path forward.

Typical PAH Formulary Alternatives

Cigna typically covers several PAH medication classes, though specific formulary placement varies by plan. Here's an educational overview of common alternatives:

Phosphodiesterase Type 5 Inhibitors

  • Sildenafil (Revatio) and tadalafil (Adcirca) are often preferred formulary agents
  • Generally require prior authorization confirming WHO Group 1 PAH diagnosis
  • Contraindicated with nitrates, nitric oxide donors, alpha blockers, and riociguat
  • Common side effects: headache, heartburn, low blood pressure, back pain

Endothelin Receptor Antagonists (ERAs)

  • Ambrisentan (Letairis) may have preferred status on some Cigna plans
  • Bosentan and macitentan are alternatives with different interaction profiles
  • All ERAs require monthly liver function monitoring
  • Contraindicated in pregnancy (Category X)
  • Ambrisentan has fewer drug interactions compared to bosentan

Other Prostacyclin Pathway Agents

  • Treprostinil (various formulations: oral, inhaled, subcutaneous, IV)
  • Epoprostenol (IV) for severe cases
  • Iloprost (inhaled) for specific patient populations
Note: Current treatment guidelines recommend early combination therapy with an ERA plus PDE5 inhibitor for most newly diagnosed PAH patients, with prostacyclin pathway agents like Uptravi added for inadequate response or higher-risk patients.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all PAH medications Cigna Precertification Portal
WHO Group 1 Diagnosis Must be confirmed via right heart catheterization Cardiology/pulmonology records
Specialist Prescriber Cardiologist or pulmonologist required Provider credentials
Functional Class NYHA/WHO functional class II-IV typically 6-minute walk test, clinical assessment
Authorization Duration Initial: 1 year, Renewal: 1 year Cigna policy documents
Appeal Deadline 180 days for internal, 120 days for external NC Smart NC Program

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Patient and clinic staff
What: Insurance card, right heart catheterization results, functional class assessment, prior therapy records
Timeline: 1-2 business days

2. Prescriber Submits Prior Authorization

Who: Cardiologist or pulmonologist
What: Complete PA form with clinical justification
How: Cigna provider portal or precertification phone line
Timeline: Same day submission possible

3. Cigna Reviews Request

Who: Cigna utilization management
What: Medical necessity review against coverage criteria
Timeline: 72 hours for standard, 24 hours for expedited

4. Receive Determination

Who: Patient and prescriber notified
What: Approval with authorization number or denial with reason
Next step: If denied, proceed to appeal process

5. If Approved: Fill Prescription

Who: Patient
What: Take approval to specialty pharmacy (likely Accredo)
Timeline: 3-5 business days for delivery

Exception Strategy for Non-Formulary Drugs

If Uptravi isn't on your Cigna formulary, you can request a formulary exception. Cigna's exception process allows coverage for non-formulary drugs when medically necessary.

Required Physician Certification

Your prescriber must certify in writing that:

  • You've tried formulary PAH drugs that were ineffective or caused adverse effects
  • You're currently receiving positive outcomes on the recommended therapy
  • Formulary alternatives are contraindicated for your condition
  • Step therapy requirements would be inappropriate for your case

Review Timeline

  • Standard review: 72 hours from receipt
  • Expedited review: 24 hours for urgent cases

Clinical Evidence That Helps

  • Documentation of failed trials with specific formulary alternatives
  • Adverse event reports from previous therapies
  • Current functional status and treatment goals
  • Relevant clinical guidelines supporting Uptravi use
  • Contraindication documentation for available alternatives

Appeals Playbook for North Carolina

North Carolina offers robust consumer protections through the Smart NC program for insurance appeals.

Internal Appeals (Cigna)

  • First level: 180 days from denial date
  • Second level: Available if first appeal denied
  • Expedited: Available for urgent medical situations
  • How to file: Cigna member portal or written request

External Review (Smart NC)

  • Deadline: 120 days after final internal denial
  • Contact: Smart NC at 1-855-408-1212
  • Timeline: 45 days for standard, 72 hours for expedited
  • Cost: Free to consumers
  • Binding: Decision is final and binding on Cigna

Required Documentation

  • Copy of denial letter
  • Medical records supporting medical necessity
  • Prescriber statement of clinical rationale
  • Evidence of exhausted internal appeals (unless expedited)
Tip: Smart NC staff can help you complete the external review application and gather supporting documentation. Their assistance is free and can significantly improve your chances of success.

Switching Logistics & Provider Coordination

When transitioning between PAH medications, careful coordination prevents treatment gaps and adverse outcomes.

Provider Communication

  • Schedule follow-up within 3-6 months of starting new therapy
  • Document baseline functional status (6-minute walk test, functional class)
  • Monitor for drug interactions with current medications
  • Plan for titration schedules if switching to Uptravi later

Specialty Pharmacy Coordination

  • Cigna typically uses Express Scripts/Accredo for specialty drugs
  • Transfer prescriptions require new prior authorization
  • Allow 5-7 business days for medication delivery
  • Coordinate timing to avoid treatment gaps

Documentation During Trial

Keep detailed records of:

  • Treatment response (functional improvement, symptom relief)
  • Adverse effects or tolerability issues
  • Adherence to prescribed regimens
  • Objective measures (walk distance, vital signs)

Re-trying for Uptravi Later

If you start with an alternative PAH medication, you can request Uptravi authorization later by demonstrating:

Medical Necessity Criteria

  • Inadequate response: Less than 30-meter improvement in 6-minute walk test after adequate trial
  • Functional decline: Worsening WHO functional class despite current therapy
  • Adverse effects: Documented intolerance to current medications
  • Clinical progression: Evidence of disease advancement requiring treatment escalation

Documentation to Gather

  • Serial 6-minute walk test results
  • Functional class assessments over time
  • Adverse event logs with severity ratings
  • Current medication adherence records
  • Updated hemodynamic data if available

Timing Considerations

Most insurers require at least 90 days of adequate trial with formulary alternatives before considering exceptions. Plan your request timeline accordingly.

Common Denial Reasons & Fixes

Denial Reason How to Overturn
Insufficient diagnosis documentation Submit right heart catheterization report with WHO Group 1 confirmation
Missing specialist requirement Ensure cardiologist or pulmonologist submits request
Lack of prior therapy trials Document failed/inadequate response to formulary alternatives
Incomplete functional assessment Provide 6-minute walk test and WHO functional class documentation
Drug interaction concerns Submit medication reconciliation with safety assessment
Quantity limit exceeded Justify dosing with clinical rationale and titration plan

FAQ

How long does Cigna prior authorization take in North Carolina? Standard reviews take up to 72 hours, while expedited reviews are completed within 24 hours for urgent medical situations.

What if Uptravi is non-formulary on my Cigna plan? You can request a formulary exception with physician certification of medical necessity. The review timeline is 72 hours for standard requests.

Can I request an expedited appeal if my condition is worsening? Yes, both Cigna internal appeals and North Carolina external reviews offer expedited processes for urgent medical situations that could jeopardize your health.

Does step therapy apply if I've tried PAH medications outside North Carolina? Yes, documented trials from other states count toward step therapy requirements. Ensure your provider includes complete treatment history in the PA request.

How much does Uptravi cost without insurance? Retail prices typically range $9,000-$25,000 for a 30-day supply. Check the Uptravi manufacturer website for current copay assistance programs.

What's the success rate for PAH medication appeals in North Carolina? While specific data for PAH medications isn't available, North Carolina's external review program has helped many patients access specialty medications through impartial review of medical necessity.

Counterforce Health specializes in helping patients navigate complex prior authorization and appeals processes for specialty medications like Uptravi. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific coverage criteria. By leveraging payer-specific workflows and clinical guidelines, we help patients and providers build stronger cases for medication approval.

For patients facing repeated denials or complex appeals, Counterforce Health can help identify the specific evidence needed to meet your plan's requirements and streamline the appeals process.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan benefits and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance appeals in North Carolina, contact Smart NC at 1-855-408-1212.

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