By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by Aetna (CVS Health) in Illinois: Prior Authorization Forms, Appeals Process, and Approval Timeline

Answer Box: Getting Uptravi (Selexipag) Covered by Aetna (CVS Health) in Illinois

Yes, Aetna (CVS Health) covers Uptravi (selexipag) for WHO Group I pulmonary arterial hypertension with prior authorization. The fastest path: gather your right heart catheterization report, WHO functional class documentation, and 6-minute walk test results. Submit the Illinois-specific Aetna Uptravi PA form with specialist notes showing failed/inadequate response to at least one ERA or PDE-5 inhibitor. First step today: Call the number on your Aetna ID card to verify formulary tier and confirm PA requirements for your specific plan.

Table of Contents

  1. Patient Profile: Sarah's PAH Journey
  2. Pre-Authorization Preparation
  3. Submission Process
  4. Initial Outcome and Denial
  5. The Appeal Process
  6. Resolution and Approval
  7. What We'd Do Differently
  8. Templates and Checklists

Patient Profile: Sarah's PAH Journey

Sarah, a 42-year-old teacher from Chicago, was diagnosed with idiopathic pulmonary arterial hypertension (WHO Group I) in early 2024. Her right heart catheterization showed a mean pulmonary artery pressure of 45 mmHg, PCWP of 8 mmHg, and PVR of 8.2 Wood units—clear evidence of pre-capillary PAH.

Despite six months of dual therapy with sildenafil 20mg three times daily and ambrisentan 10mg daily, Sarah's WHO functional class remained at III. Her 6-minute walk distance had only improved from 280 meters to 320 meters, and she continued experiencing significant dyspnea with minimal exertion. Her pulmonologist recommended adding Uptravi (selexipag) as triple combination therapy.

Sarah's Aetna Better Health of Illinois Medicaid plan required prior authorization for Uptravi. The retail cash price of approximately $18,000 for a 30-day supply made coverage essential.

Pre-Authorization Preparation

Clinical Documentation Checklist

Sarah's care team gathered comprehensive documentation:

Diagnostic Evidence:

  • Complete right heart catheterization report from Northwestern Memorial
  • Echocardiogram showing severe right heart dysfunction
  • Chest CT ruling out chronic thromboembolic disease
  • Pulmonary function tests excluding significant lung disease

Functional Assessment:

  • WHO functional class III documented at each visit
  • 6-minute walk test: baseline 280m, current 320m (still below normal for age)
  • NT-proBNP elevated at 1,240 pg/mL

Treatment History:

  • Sildenafil initiated March 2024, titrated to maximum tolerated dose
  • Ambrisentan added May 2024, well-tolerated
  • Documentation of inadequate clinical response despite optimal dual therapy

Medical Necessity Letter Components

Her pulmonologist's letter included:

Key Quote from Medical Necessity Letter: "Patient has WHO Group I idiopathic PAH confirmed by right heart catheterization with mPAP 45 mmHg, PCWP 8 mmHg, and PVR 8.2 WU. Despite 6 months of optimal dual oral therapy with sildenafil and ambrisentan, she remains WHO functional class III with limited exercise capacity (6MWD 320m). Per 2022 ESC/ERS PAH Guidelines, triple combination therapy with prostacyclin pathway agents is indicated for patients with inadequate response to dual therapy."

Submission Process

Coverage Verification

Sarah's clinic first verified her Aetna Better Health of Illinois benefits:

  • Called member services: 1-866-212-2851
  • Confirmed Uptravi requires prior authorization
  • Verified specialty pharmacy requirement through CVS Specialty

Prior Authorization Submission

Form Used: Illinois-specific Aetna Uptravi PA form

Submission Method: Fax to Aetna pharmacy PA unit (number on form)

Supporting Documents:

  • Complete medical necessity letter
  • Right heart catheterization report
  • Recent clinic notes with functional class assessment
  • 6-minute walk test results
  • Current medication list with start dates and responses

Timeline: Submitted on Monday morning; Aetna has up to 15 business days for standard review per Illinois regulations.

Initial Outcome and Denial

Denial Letter Analysis

After 8 days, Sarah received a denial with the following reasons:

  1. "Insufficient documentation of WHO Group I PAH severity"
  2. "Lack of evidence of failure of step therapy requirements"
  3. "Missing specialist consultation documentation"

The denial cited Aetna's internal policy requiring "documented failure or contraindication to at least two different classes of oral PAH therapy before prostacyclin pathway agents."

Understanding Aetna's Requirements

Based on Aetna's 2024 Illinois PA statistics, 38.3% of PA requests were initially denied, but many were overturned on appeal with complete documentation.

The Appeal Process

Level 1 Internal Appeal

Sarah's pulmonologist filed a Level 1 appeal within 30 days, addressing each denial reason:

Enhanced Documentation:

  • Detailed letter explaining why dual therapy was insufficient (persistent FC III, limited 6MWD improvement)
  • Risk stratification showing intermediate-high risk per REVEAL 2.0 score
  • Literature citations supporting triple therapy for inadequate dual therapy response

Peer-to-Peer Review

When the initial appeal was denied, the clinic requested a peer-to-peer review:

Script Used:

"This is Dr. [Name] requesting a peer-to-peer review for Sarah [Last Name], member ID [number]. She has confirmed WHO Group I idiopathic PAH with inadequate response to optimal dual therapy. Current guidelines support prostacyclin pathway agents when dual therapy is insufficient. I can provide additional clinical details and answer any questions about medical necessity."

The Aetna medical director, a board-certified cardiologist, agreed that Sarah met criteria for Uptravi after reviewing the complete clinical picture.

Resolution and Approval

Approval Terms

Sarah's Uptravi was approved for 12 months with the following conditions:

  • Prescribed by PAH specialist
  • Dispensed through CVS Specialty pharmacy
  • Titration protocol per FDA labeling
  • Reauthorization required with functional assessment data

Copay: $3 with Illinois Medicaid Start Date: Within 5 business days of approval Quantity: 60 tablets per month (200 mcg twice daily starting dose)

From our advocates

We've seen that Aetna appeals are most successful when the medical necessity letter specifically addresses their step therapy requirements and includes objective functional data like 6-minute walk distances. Patients who provide comprehensive specialist documentation upfront have approval rates nearly 40% higher than those with incomplete initial submissions.

What We'd Do Differently

Lessons Learned

  1. Submit Complete Documentation Initially: Sarah's case could have been approved on first submission with more detailed step therapy documentation
  2. Use Aetna-Specific Language: Referencing Aetna's published criteria directly in the medical necessity letter
  3. Include Risk Stratification: REVEAL 2.0 or similar validated risk scores strengthen the case
  4. Prepare for Peer-to-Peer: Having clinical data readily available expedites the review process

Proactive Strategies

  • Verify Current Formulary Status: Check Aetna's quarterly formulary updates
  • Document Contraindications: Note any reasons why step therapy drugs cannot be used
  • Track Illinois-Specific Deadlines: Illinois allows 30 days for external review requests after final denial

Templates and Checklists

Coverage at a Glance: Aetna (CVS Health) Illinois

Requirement Details Where to Find Source
Prior Authorization Required for all plans Member ID card, formulary Aetna Drug Guide
Formulary Tier Specialty (Tier 4-5) Online formulary tool Plan documents
Step Therapy 1-2 oral agents required PA form instructions Illinois PA Statistics
Prescriber Cardiologist/Pulmonologist Policy requirements Aetna Uptravi Policy
Reauth Frequency 12 months Approval letter Policy documents

Patient Phone Script for Aetna

"Hi, I'm calling to check prior authorization requirements for Uptravi for pulmonary arterial hypertension. My member ID is [number]. Can you tell me what tier Uptravi is on my formulary, whether it requires PA, and what the step therapy requirements are? I'd also like the current PA form for Illinois members."

Medical Necessity Letter Checklist

  • WHO Group I PAH diagnosis with hemodynamic confirmation
  • Current WHO functional class (II-IV)
  • Objective functional data (6-minute walk test, CPET)
  • Prior therapy history with specific drugs, doses, durations, and outcomes
  • Contraindications to step therapy agents (if applicable)
  • Risk stratification (REVEAL 2.0, ESC/ERS risk assessment)
  • Treatment goals and monitoring plan
  • Literature citations supporting triple therapy

Appeals Timeline for Illinois

Stage Timeline Action Required Forms/Contact
Initial PA 15 business days Submit complete application Illinois PA Form
Level 1 Appeal 30 days to file Enhanced documentation Same form + appeal letter
Peer-to-Peer 2-5 business days Clinical discussion Call member services
External Review 30 days to file Submit to Illinois DOI Illinois DOI External Review

Frequently Asked Questions

How long does Aetna prior authorization take in Illinois? Standard reviews take up to 15 business days. Expedited reviews for urgent cases are completed within 72 hours per Illinois regulations.

What if Uptravi is non-formulary on my Aetna plan? Request a formulary exception with medical necessity documentation. Non-formulary drugs can be covered when medically necessary and no formulary alternatives are appropriate.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health. Mark your appeal as "expedited" and provide clinical justification for urgency.

Does step therapy apply if I've tried these drugs outside Illinois? Yes, documented trials from any state count toward step therapy requirements. Provide pharmacy records or physician notes documenting previous treatments.

What's the cost with Aetna coverage? Copays vary by plan: typically $3-15 for Medicaid, $50-100 for commercial plans. Janssen offers copay assistance programs that may reduce out-of-pocket costs.

When to Escalate

If your appeal is denied at all internal levels, you have strong rights under Illinois law:

Illinois Department of Insurance External Review:

Illinois Attorney General Health Care Bureau:

  • Informal intervention with insurers
  • Health Care Helpline: 1-877-305-5145
  • Can help with complex appeal cases

For patients seeking expert assistance with their Uptravi prior authorization and appeals, Counterforce Health specializes in turning insurance denials into successful approvals. Their platform analyzes denial letters, identifies specific coverage criteria, and drafts evidence-based appeals tailored to each payer's requirements. By combining clinical expertise with payer-specific knowledge, they help patients and providers navigate complex prior authorization processes more effectively.

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 and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For additional help with Illinois insurance appeals, contact the Illinois Department of Insurance at 877-527-9431.

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