By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by Aetna CVS Health in Texas: Complete PA Guide and Appeals Process

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

Eligibility: Aetna CVS Health requires prior authorization for Uptravi (selexipag) with strict documentation: WHO Group I PAH diagnosis, right heart catheterization results, functional class II-IV status, and failure of 2+ oral PAH therapies (60 days each). Fastest path: Have your pulmonologist or cardiologist complete the specialty PA form with hemodynamic data, prior therapy records, and medical necessity letter. First step today: Download the current PA form from the Aetna provider portal and gather your right heart cath report and prior medication trial documentation.

Table of Contents

  1. Policy Overview: How Aetna CVS Health Covers Uptravi in Texas
  2. Medical Necessity Requirements
  3. Step Therapy and Exception Pathways
  4. Required Documentation and Diagnostics
  5. Specialty Pharmacy and Site of Care Rules
  6. Appeals Process for Texas Residents
  7. Common Denial Reasons and Solutions
  8. Cost Support and Patient Resources
  9. FAQ: Uptravi Coverage Questions

Policy Overview: How Aetna CVS Health Covers Uptravi in Texas

Aetna CVS Health classifies Uptravi (selexipag) as a specialty medication requiring prior authorization across all plan types in Texas—including HMO, PPO, and Medicare Advantage plans. The drug is typically placed on higher formulary tiers due to its cost (retail prices range $9,000–$25,000 per 30-day supply) and specialized indication for pulmonary arterial hypertension.

Plan Types and Coverage:

  • Commercial plans: Full PA requirements apply with step therapy protocols
  • Medicare Advantage: Additional CMS guidelines for specialty drugs
  • Medicaid managed care: May have separate state-specific criteria

All specialty medications are processed through CVS Caremark's specialty pharmacy division, which handles both the PA review and drug dispensing.

Medical Necessity Requirements

Core Eligibility Criteria

Prescriber Requirements:

  • Must be a pulmonologist or cardiologist with documented specialty credentials
  • NPI number and specialty designation required on all forms

Diagnosis Documentation:

  • ICD-10 codes: I27.0 (Primary pulmonary hypertension) or I27.21 (Secondary pulmonary arterial hypertension)
  • Confirmed WHO Group I PAH diagnosis
  • Functional Class II, III, or IV status documented

Hemodynamic Evidence: Your right heart catheterization must show:

  • Mean pulmonary artery pressure (mPAP) >20 mmHg
  • Pulmonary capillary wedge pressure (PCWP) ≤15 mmHg
  • Pulmonary vascular resistance (PVR) ≥3 Wood units

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization PA form required before dispensing Aetna provider portal 30-45 days standard
Step Therapy 2+ oral PAH therapies tried first Medical records, pharmacy claims 60+ days per therapy
Specialist Prescriber Pulmonologist or cardiologist only Provider credentials N/A
Hemodynamic Data Right heart cath within 6-12 months Hospital/clinic records Recent preferred
Functional Assessment WHO Class II-IV documented Clinical notes, 6-minute walk test Current status

Step Therapy and Exception Pathways

Required Prior Therapies

Before approving Uptravi, Aetna CVS Health requires documented trials of at least 2 different oral PAH therapy classes, each for a minimum of 60 days:

Preferred First-Line Options:

  • PDE-5 inhibitors: Sildenafil (Revatio), tadalafil (Adcirca)
  • Endothelin receptor antagonists: Bosentan (Tracleer), ambrisentan (Letairis)
  • Soluble guanylate cyclase stimulators: Riociguat (Adempas)

Medical Exception Process

If step therapy requirements cannot be met, submit a formulary exception request with detailed justification:

Exception Criteria:

  • Contraindications to required therapies
  • Previous intolerance with documented adverse effects
  • Drug interactions with current medications
  • Clinical urgency requiring immediate prostacyclin pathway therapy

Submission Process:

Clinician Corner: Medical Necessity Letter Checklist

Your letter should include:Patient's specific PAH diagnosis and functional classComplete right heart catheterization results with datesDetailed history of prior PAH therapies tried, including:Medication names and dosagesDuration of each trial (minimum 60 days)Specific reasons for discontinuation or failureDocumented adverse effects or contraindicationsClinical rationale for Uptravi specificallyReference to FDA-approved indication for PAHPlanned dosing and titration schedule

Required Documentation and Diagnostics

Essential Clinical Records

Hemodynamic Assessment:

  • Right heart catheterization report (within 6-12 months)
  • Complete hemodynamic measurements including pressures and resistance calculations
  • Confirmation of WHO Group I classification

Functional Assessment:

  • Current WHO/NYHA functional class determination
  • Six-minute walk test results (baseline and follow-up if available)
  • Documentation of activity limitations and symptoms

Laboratory and Imaging:

  • Echocardiogram results
  • Pulmonary function tests
  • BNP or NT-proBNP levels
  • Complete blood count and comprehensive metabolic panel

Documentation Tips

  • Ensure all reports are dated and include patient identifiers
  • Provide complete medication histories with specific dates and outcomes
  • Include any relevant imaging studies showing right heart changes
  • Document contraindications to required step therapy medications

Specialty Pharmacy and Site of Care Rules

Dispensing Requirements:

  • Uptravi must be dispensed through CVS Specialty Pharmacy or approved network specialty pharmacies
  • Cannot be filled at retail pharmacies
  • Prior authorization must be approved before first shipment

Administration and Monitoring:

  • Oral medication for home administration
  • No infusion site requirements (unlike IV prostacyclins)
  • Regular specialty pharmacy consultations for titration guidance
  • Ongoing monitoring through prescribing specialist

NDC and Coding:

  • Ensure correct NDC codes are used on PA forms
  • For billing purposes, may require HCPCS code J3490 for unlisted drugs in certain settings

Appeals Process for Texas Residents

Internal Appeals with Aetna CVS Health

Timeline and Process:

  • Deadline: 180 days from denial date to file internal appeal
  • Standard review: 30 days for pre-service decisions, 60 days for post-service
  • Expedited appeals: 72 hours when delay could jeopardize health

Required Documentation:

  • Original denial letter
  • Additional medical evidence supporting necessity
  • Updated physician letter addressing specific denial reasons
  • Any new clinical data or test results

External Review Through Texas

If your internal appeal is denied, Texas law provides access to Independent Review Organization (IRO) review:

IRO Process:

  • Deadline: 4 months from final internal denial
  • Cost: No charge to patient (Aetna pays IRO fees)
  • Timeline: 20 days for standard review, 5 days for expedited
  • Contact: Texas Department of Insurance at 1-800-252-3439

IRO Decision:

  • Binding on Aetna CVS Health
  • Based solely on medical necessity and appropriateness
  • Cannot be appealed further through state process
Note: ERISA self-funded employer plans may follow different federal appeal procedures. Verify your plan type with your employer's benefits administrator.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Incomplete hemodynamic data Submit full right heart cath report Complete catheterization with all pressure measurements
Step therapy not met Document prior failures/intolerance Detailed medication history with outcomes
Non-specialist prescriber Transfer to PAH specialist Pulmonologist or cardiologist prescription
Insufficient functional class documentation Provide current assessment WHO class determination, 6-minute walk test
Drug interactions not addressed Review contraindications Medication reconciliation, interaction assessment
"Experimental/investigational" Cite FDA approval FDA label, clinical guidelines

When Standard Appeals Fail

For complex cases, consider:

  • Peer-to-peer review: Request direct physician-to-physician discussion
  • External medical review: Independent clinical assessment
  • State insurance department complaint: Texas Department of Insurance

Cost Support and Patient Resources

Manufacturer Support:

  • Janssen CarePath program offers copay assistance and patient support
  • Income-based eligibility requirements apply
  • Cannot be combined with government insurance programs

Foundation Assistance:

  • Patient Access Network (PAN) Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

State Resources:

  • Texas Department of Insurance consumer assistance: 1-800-252-3439
  • Office of Public Insurance Counsel (OPIC): 1-877-611-6742

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements like those for Uptravi. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address each payer's specific criteria. By identifying the exact denial basis—whether it's step therapy, non-formulary status, or missing clinical documentation—we help turn insurance denials into successful approvals.

FAQ: Uptravi Coverage Questions

How long does Aetna CVS Health prior authorization take for Uptravi in Texas? Standard PA decisions take 30-45 days. Expedited reviews for urgent medical needs are processed within 72 hours. Submit through the Aetna provider portal or fax to 1-888-267-3277.

What if Uptravi is non-formulary on my plan? Request a formulary exception using the same PA process. Include detailed medical necessity justification and documentation of why preferred formulary alternatives are inappropriate or ineffective.

Can I get expedited approval if my condition is worsening? Yes, if your physician documents that delays in treatment could jeopardize your health. Mark requests as "urgent" and provide clinical justification for expedited review.

Do out-of-state prior therapy trials count toward step therapy? Yes, documented trials from other states count toward Aetna's step therapy requirements. Include complete medical records and pharmacy claims from previous treatments.

What happens if my appeal is denied? Texas residents can request Independent Review Organization (IRO) review within 4 months of the final denial. The IRO decision is binding on Aetna CVS Health.

How do I find an in-network PAH specialist? Use Aetna's provider directory online or call member services. Look specifically for pulmonologists or cardiologists with PAH expertise at major medical centers.

Can nurse practitioners prescribe Uptravi? Most Aetna plans require prescriptions from specialists (pulmonologists or cardiologists). Nurse practitioners may prescribe only with specialist oversight and plan approval.

What if I'm switching from another PAH medication? Document the clinical reason for switching, whether it's lack of efficacy, adverse effects, or disease progression. Include recent functional assessments and hemodynamic data.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Aetna CVS Health and consult with your healthcare provider for medical decisions. For assistance with Texas insurance disputes, contact the Texas Department of Insurance at 1-800-252-3439.

When navigating complex insurance requirements for specialty medications like Uptravi, having expert support can make the difference between approval and denial. Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed responses that address each payer's specific criteria and procedural requirements.

Sources & Further Reading

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