By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by Blue Cross Blue Shield in New Jersey: Complete Coverage Guide

Quick Answer: To get Uptravi (selexipag) covered by Blue Cross Blue Shield in New Jersey, you'll need prior authorization with WHO Group I PAH diagnosis, right heart catheterization results, 6-minute walk test, and WHO functional class documentation. Submit through Horizon BCBS portal or CoverMyMeds. If denied, use New Jersey's IHCAP external review program managed by Maximus. Start by gathering your PAH specialist's clinical notes and hemodynamic data from the last 6 months.

Table of Contents

Coverage Overview: BCBS New Jersey Policy

Uptravi (selexipag) requires prior authorization under Horizon Blue Cross Blue Shield of New Jersey for all commercial plans as of 2024. The medication is typically covered as a specialty drug when prescribed for WHO Group I pulmonary arterial hypertension (PAH) by a cardiologist or pulmonologist.

Key Policy Details:

  • Formulary Status: Specialty tier (varies by plan)
  • Prior Authorization: Required for all strengths
  • Quantity Limits: Up to maximum FDA-approved dose (1600 mcg twice daily)
  • Site of Care: Specialty pharmacy required
  • Prescriber Requirements: Must be PAH specialist
Note: Horizon BCBS is New Jersey's largest insurer with approximately 39% market share. Other Blues plans in the state may have similar but not identical policies.

Medical Necessity Requirements

Horizon BCBS New Jersey follows strict medical necessity criteria for Uptravi approval:

Primary Diagnosis Requirements

  • WHO Group I PAH confirmed by right heart catheterization
  • Mean pulmonary arterial pressure (mPAP) > 20 mmHg at rest
  • Pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg
  • Pulmonary vascular resistance (PVR) > 2 Wood units

Functional Assessment

  • WHO functional class II, III, or IV clearly documented
  • 6-minute walk test results from within 6 months
  • Clinical notes from PAH specialist dated within last 6 months

Additional Criteria

  • Prescriber must be a cardiologist or pulmonologist experienced in PAH treatment
  • Documentation of current or planned combination PAH therapy may be required
  • No contraindications to prostacyclin pathway agonists

Step-by-Step: Fastest Path to Approval

  1. Gather Clinical Documentation (Patient/Clinic)
    • Right heart catheterization report with hemodynamic values
    • Recent 6-minute walk test results
    • WHO functional class assessment
    • Timeline: 1-2 business days to collect
    • Source: Horizon PA Requirements
  2. Complete Prior Authorization Form (Prescriber)
    • Use current Horizon BCBS PA form
    • Include all required clinical attachments
    • Timeline: 2-3 business days
    • Submit via: CoverMyMeds or Horizon provider portal
  3. Submit Supporting Evidence (Prescriber)
    • Clinical notes justifying medical necessity
    • Treatment history and prior therapy documentation
    • Timeline: Same day as PA submission
    • Source: Horizon Provider Portal
  4. Track Application Status (Patient/Clinic)
    • Monitor through provider portal or CoverMyMeds
    • Standard determination: up to 14 calendar days
    • Expedited: up to 72 hours (if urgent)
  5. Prepare for Potential Peer-to-Peer (Prescriber)
    • Be available for clinical discussion if requested
    • Have patient chart and guidelines ready
    • Timeline: Usually within 5 business days of initial review

Required Documentation Checklist

Essential Clinical Documents

  • ✓ Right heart catheterization report (complete hemodynamic data)
  • ✓ 6-minute walk test results (distance in meters, date performed)
  • ✓ WHO functional class assessment (I, II, III, or IV with supporting symptoms)
  • ✓ PAH specialist consultation notes (within 6 months)
  • ✓ Current medication list (including other PAH therapies)

Administrative Requirements

  • ✓ Completed PA form (latest Horizon BCBS version)
  • ✓ Insurance card copy
  • ✓ Prescriber NPI and specialty designation
  • ✓ ICD-10 diagnosis code (typically I27.0 for idiopathic PAH)

Supporting Evidence

  • ✓ Treatment history (prior PAH medications tried)
  • ✓ Contraindications to alternative therapies (if applicable)
  • ✓ Dosing rationale for requested strength/quantity
Clinician Corner: When writing the medical necessity letter, structure it as: (1) PAH diagnosis with hemodynamic confirmation, (2) current functional status and symptoms, (3) prior treatment history, (4) clinical rationale for Uptravi, and (5) monitoring plan. Reference the FDA label and relevant PAH guidelines.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Incomplete hemodynamic data Submit full right heart catheterization report mPAP, PCWP, PVR values with dates
Missing functional assessment Provide WHO functional class with 6MWT Test results within 6 months
Non-specialist prescriber Transfer prescription to PAH expert Cardiologist or pulmonologist
Insufficient prior therapy documentation Detail previous PAH treatments Medication history with dates, outcomes
Quantity limit exceeded Justify dosing based on titration FDA-approved titration schedule

New Jersey Appeals Process

If your Uptravi prior authorization is denied, New Jersey offers robust appeal rights:

Internal Appeals (Horizon BCBS)

  • Level 1: Standard internal appeal
  • Timeline: 30 days from denial to file
  • Decision: Within 30 days for standard, 72 hours for expedited
  • Submit to: Horizon BCBS appeals department

External Review (IHCAP)

New Jersey's Independent Health Care Appeals Program provides binding external review:

  • Managed by: Maximus Federal Services
  • Timeline: 4 months (180 days) from final denial to file
  • Decision: 45 days for standard, 72 hours for expedited
  • Cost: Free to patient (insurer pays all costs)
  • Submit to: Maximus IHCAP Portal

Required for External Appeal:

  • Final denial letter from Horizon BCBS
  • All internal appeal decisions
  • Signed consent forms
  • Supporting medical documentation
  • Completed IHCAP request form
Success Rates: Approximately 50% of external appeals nationwide favor consumers, and New Jersey's IHCAP has strong consumer protections under state law.

Contact Information:

  • IHCAP Hotline: 1-888-393-1062
  • NJ DOBI Consumer Hotline: 1-800-446-7467
  • Email: [email protected]

Cost Savings Options

Even with insurance coverage, Uptravi can be expensive. Consider these assistance programs:

Manufacturer Support

  • Janssen CarePath: Copay assistance and patient support services
  • Eligibility: Commercial insurance patients (not government programs)
  • Website: JanssenCarePath.com

Patient Assistance Programs

  • Johnson & Johnson Patient Assistance Foundation: Free medication for qualifying patients
  • Income limits: Typically 300-500% of federal poverty level
  • Application: Through healthcare provider

Specialty Pharmacy Benefits

  • Many specialty pharmacies offer additional copay assistance and care coordination
  • Horizon BCBS contracts with specific specialty pharmacy networks

FAQ

How long does Horizon BCBS prior authorization take in New Jersey? Standard determinations take up to 14 calendar days. Expedited requests (for urgent medical needs) are decided within 72 hours. Track status through the provider portal or CoverMyMeds.

What if Uptravi is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are contraindicated or have failed. The appeal process is the same as for PA denials.

Can I request an expedited appeal if I'm already on Uptravi? Yes, if stopping the medication would cause serious harm to your health. Document the medical urgency and submit through both Horizon's expedited process and, if needed, IHCAP's urgent external review.

Does step therapy apply to Uptravi? Horizon BCBS may require documentation of other PAH therapies tried first, depending on your specific plan. However, medical exceptions are available if you have contraindications or have failed step therapy requirements.

What happens if I move from another state while on Uptravi? Contact Horizon BCBS immediately to transfer your authorization. Provide documentation from your previous insurer and current prescriber. New Jersey cannot deny coverage based solely on treatments started in other states.

How often do I need to renew prior authorization? Most Horizon BCBS plans require annual renewal with updated clinical documentation showing continued medical necessity and treatment response.

Getting prescription drugs approved by insurance can feel overwhelming, but you don't have to navigate it alone. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, payer-specific responses that address denial reasons point-by-point. Their platform ingests denial letters, plan policies, and clinical notes to draft targeted rebuttals aligned with each insurer's own rules.

When working with your healthcare team to secure Uptravi coverage, remember that Counterforce Health can provide additional support if you face denials or need help strengthening your appeal with the right clinical evidence and documentation.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently—always verify current requirements with your specific insurance plan. For questions about New Jersey insurance regulations or to file complaints, contact the NJ Department of Banking and Insurance at 1-800-446-7467.

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