By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by Blue Cross Blue Shield in California: Complete Requirements Guide

Answer Box: Getting Uptravi Covered by Blue Cross Blue Shield California

Uptravi (selexipag) requires prior authorization from Blue Cross Blue Shield of California for WHO Group I pulmonary arterial hypertension. To get approved: (1) Submit clinical documentation proving PAH diagnosis with right heart catheterization data, (2) Include 6-minute walk test results and WHO functional class, (3) Use the AuthAccel portal or fax forms to (888) 697-8122. If denied, California residents can appeal through Independent Medical Review (IMR) with high success rates. Start today: Verify your formulary status and gather hemodynamic data from your cardiologist.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding and Billing Requirements
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission: Tracking Your Request
  9. Appeals Process in California
  10. Common Denial Reasons & Solutions
  11. Quick Reference Checklist

Who Should Use This Guide

This guide helps California patients with pulmonary arterial hypertension (PAH) and their healthcare providers navigate Blue Cross Blue Shield's prior authorization process for Uptravi (selexipag). You'll need this if:

  • Your doctor has prescribed Uptravi for WHO Group I PAH
  • You have Blue Shield of California commercial or Medicare coverage
  • You've received a denial letter for Uptravi coverage
  • You're preparing an initial prior authorization request

Expected outcome: With complete documentation meeting Blue Shield's clinical criteria, most medically appropriate requests get approved. If denied, California's Independent Medical Review process has a 74.7% success rate for overturning Blue Shield denials.

Member & Plan Basics

Coverage Requirements

  • Active Blue Shield of California membership (commercial, Medicare Advantage, or FEP)
  • Current insurance card with member ID
  • Verify Uptravi appears on your plan's formulary with "PA" designation

Plan Types and Authorization

Blue Shield requires prior authorization for Uptravi across all plan types. Check your specific formulary at Blue Shield's drug list portal to confirm current status.

Tip: Federal Employee Program (FEP) members have different procedures—authorizations go through CVS Caremark at (888) 346-3731.

Clinical Criteria for Approval

Blue Shield of California approves Uptravi only when strict clinical criteria are met, as outlined in their April 2024 policy:

Required Diagnosis

  • WHO Group I pulmonary arterial hypertension confirmed by:
    • Mean pulmonary arterial pressure (mPAP) > 20 mmHg
    • Pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg
    • Pulmonary vascular resistance (PVR) > 2 Wood units

Functional Status Documentation

  • WHO functional class II, III, or IV
  • Recent 6-minute walk test with distance recorded
  • Clinical notes documenting symptoms and functional limitations

ICD-10 Diagnostic Codes

Accepted codes include:

  • I27.0 - Primary pulmonary hypertension
  • I27.2 - Secondary pulmonary arterial hypertension
  • I27.89 - Other specified pulmonary heart diseases

Coding and Billing Requirements

HCPCS/J-Codes

  • J3490 (unclassified drugs) - verify current code as updates occur
  • Include NDC number for specific Uptravi strength
  • Document units and dosing schedule

Dosing Parameters

  • Starting dose: 200 mcg twice daily
  • Maximum covered dose: typically up to 1800 mcg twice daily
  • Include titration plan in medical necessity documentation

Documentation Packet Essentials

Provider Note Elements

Your cardiologist or pulmonologist must include:

  1. Confirmed PAH diagnosis with right heart catheterization results
  2. Current WHO functional class and symptom severity
  3. 6-minute walk test results with date and distance
  4. Prior treatment history and response/intolerance
  5. Clinical rationale for Uptravi specifically
  6. Prescriber credentials (NPI, specialty certification)

Medical Necessity Letter Components

Use Blue Shield's requirements as your template foundation:

  • Patient demographics and insurance information
  • Detailed PAH diagnosis with hemodynamic data
  • Functional assessment (WHO class, 6MWT)
  • Treatment history and rationale for Uptravi
  • Dosing plan and monitoring strategy
  • Supporting literature references
Clinician Corner: Attach recent office notes, catheterization reports, and 6-minute walk test printouts. Missing objective data is the most common cause of denial.

Required Attachments

  • Right heart catheterization report
  • 6-minute walk test results
  • Recent clinic notes (within 6 months)
  • Prior authorization form (current version)
  • Patient insurance card copy

Submission Process

Electronic Submission (Preferred)

  1. AuthAccel Portal - Blue Shield's primary submission platform
  2. CoverMyMeds - integrates with many EHR systems
  3. Real-time status tracking available

Fax Submission

Required Fields That Cause Rejections

  • Incomplete member identification
  • Missing prescriber NPI or DEA number
  • Unsigned forms or missing dates
  • Illegible handwriting on fax submissions

For fastest processing, submit electronically through AuthAccel or CoverMyMeds with complete documentation.

Specialty Pharmacy Coordination

Preferred Network

Blue Shield contracts with specific specialty pharmacies for Uptravi distribution. Verify network status to avoid coverage issues.

Transfer Process

  1. Obtain prior authorization approval first
  2. Coordinate with Blue Shield Specialty Pharmacy Program: (888) 346-3731
  3. Confirm shipment address and delivery preferences
  4. Verify insurance billing before first shipment

After Submission: Tracking Your Request

Confirmation and Status

  • Electronic submissions: Receive confirmation number immediately
  • Fax submissions: Call (800) 535-9481 to confirm receipt
  • Status checks: Use AuthAccel portal or call member services

Timeline Expectations

  • Standard review: Up to 14 days for determination
  • Expedited review: 72 hours for urgent cases
  • Missing information: Additional 14 days if more documentation requested

Keep detailed records of all submission dates, confirmation numbers, and communications.

Appeals Process in California

California residents have robust appeal rights when Uptravi is denied by Blue Cross Blue Shield.

Internal Appeal (First Level)

  • Deadline: 60 calendar days from denial letter date
  • Process: Submit written appeal with supporting documentation
  • Timeline: Blue Shield has 60 days to reconsider

Independent Medical Review (IMR)

If your internal appeal is denied, California law provides Independent Medical Review through the Department of Managed Health Care (DMHC):

  • Eligibility: Available after internal appeal denial
  • Timeline: Standard IMR decided within 45 days; expedited within 72 hours
  • Success rate: 74.7% of medical necessity appeals against Blue Shield are resolved in favor of patients
  • No cost: IMR is free to California patients

How to Request IMR

  1. Call DMHC Help Center: (888) 466-2219
  2. Submit IMR application online at healthhelp.ca.gov
  3. Include all denial letters and supporting medical records
Note: Independent physician experts in pulmonary medicine review IMR cases. Blue Shield must comply with IMR decisions within 5 working days.

Common Denial Reasons & Solutions

Denial Reason Solution
Missing hemodynamic data Submit complete right heart catheterization report with mPAP, PAWP, and PVR values
No 6-minute walk test Provide recent 6MWT results with date and distance walked
Insufficient WHO class documentation Include detailed functional assessment in provider notes
Missing prior treatment history Document all previous PAH therapies, responses, and reasons for discontinuation
Non-specialist prescriber Ensure prescription comes from or is co-signed by cardiologist or pulmonologist

Counterforce Health helps patients and providers turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific requirements.

Quick Reference Checklist

Before Submitting

  • Verify Blue Shield coverage and formulary status
  • Confirm WHO Group I PAH diagnosis with hemodynamic data
  • Obtain recent 6-minute walk test results
  • Document WHO functional class
  • Gather prior treatment history
  • Ensure cardiologist/pulmonologist involvement

Required Documentation

  • Completed prior authorization form (current version)
  • Medical necessity letter with clinical rationale
  • Right heart catheterization report
  • 6-minute walk test printout
  • Recent clinic notes (within 6 months)
  • Insurance card copy

Submission

  • Submit via AuthAccel portal or CoverMyMeds (preferred)
  • Alternative: Fax to (888) 697-8122
  • Record confirmation number and submission date
  • Set calendar reminder to check status in 7-10 days

If Denied

  • File internal appeal within 60 days
  • Prepare for IMR if internal appeal fails
  • Contact DMHC Help Center: (888) 466-2219
  • Consider professional appeal assistance

From our advocates: "We've seen many Uptravi denials overturned when providers include specific hemodynamic numbers and 6-minute walk distances in their appeals. The key is translating clinical findings into the exact language insurers use in their coverage policies. This approach has helped numerous PAH patients access their prescribed therapy through California's IMR process."

Getting specialized help: Counterforce Health transforms insurance denials into targeted appeals by identifying the specific denial basis and drafting evidence-backed rebuttals that align with each plan's coverage criteria. The platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements for medications like Uptravi.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual medical circumstances and specific insurance plan terms. Always consult your healthcare provider about treatment options and verify current coverage requirements with Blue Cross Blue Shield of California. For personalized assistance with appeals, contact the California Department of Managed Health Care at (888) 466-2219.

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