By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (selexipag) Covered by Blue Cross Blue Shield of North Carolina: Forms, Appeals, and Success Timeline

Quick Answer: Getting Uptravi Covered by Blue Cross Blue Shield of North Carolina

Uptravi (selexipag) requires prior authorization from Blue Cross Blue Shield of North Carolina (BCBSNC). The fastest path: 1) Have your doctor submit a PA request through the Blue e provider portal with complete PAH documentation, 2) Use an in-network specialty pharmacy for dispensing, and 3) If denied, file an internal appeal within 90 days, then escalate to North Carolina's external review through Smart NC if needed. Start by calling BCBSNC provider services at 800-672-7897 to verify current PA requirements and confirm your plan's specialty drug coverage.

Table of Contents

Start Here: Verify Your Plan and Coverage

Before starting the prior authorization process, confirm your specific Blue Cross Blue Shield of North Carolina plan details. BCBSNC operates multiple product lines with varying requirements:

Essential First Steps:

  1. Check your member ID card for your specific plan type (ACA marketplace, commercial group, Medicare Advantage)
  2. Review your plan's formulary to see if Uptravi is listed and at what tier
  3. Confirm specialty drug coverage is included in your benefits
  4. Verify your provider is in-network for BCBSNC
Note: Self-funded employer plans may have different requirements than fully-insured BCBSNC plans. Call the number on your ID card to confirm your specific coverage rules.

Prior Authorization Forms and Requirements

Coverage Requirements for Uptravi

Uptravi requires prior authorization for all BCBSNC plans. The medication must meet specific clinical criteria:

Medical Necessity Requirements:

  • Confirmed diagnosis of WHO Group I pulmonary arterial hypertension (PAH)
  • Functional Class II, III, or IV symptoms
  • Documented 6-minute walk test results
  • Hemodynamic data supporting PAH diagnosis
  • Current or planned background PAH therapy plan
  • Assessment of drug interactions and contraindications

Required Documentation

Your healthcare provider must submit comprehensive clinical documentation including:

  • Diagnosis confirmation: ICD-10 codes for PAH (I27.0, I27.20-I27.29)
  • Functional assessment: WHO Functional Class status and 6-minute walk distance
  • Hemodynamic data: Right heart catheterization results confirming PAH
  • Treatment history: Prior or concurrent PAH therapies tried or planned
  • Clinical rationale: Why Uptravi is medically necessary for your specific case
  • Safety assessment: Review of contraindications and potential drug interactions

Submission Portals and Methods

Blue e Provider Portal: The fastest method for PA submissions is through BCBSNC's electronic portal at bluecrossnc.com/providers.

Portal Features:

  • Real-time status tracking
  • Secure document upload
  • Automated confirmation receipts
  • Integration with specialty pharmacy network

Alternative Submission Methods

Fax Submissions:

  • Prescription drug prior authorization: 888-348-7332
  • Include cover sheet with member ID, provider NPI, and request type

Phone Support:

  • Provider services: 800-672-7897 (24-hour availability)
  • Clinical questions and case management support available

Specialty Pharmacy Network Requirements

Uptravi must be dispensed through a participating specialty pharmacy in the BCBSNC network. Standard retail pharmacies cannot dispense this medication.

Network Specialty Pharmacies

BCBSNC Contracted Specialty Pharmacies:

  • HPC Specialty Pharmacy: 800-757-9192
  • Onco360: 877-662-6633
  • Novant Health Specialty Pharmacy: 855-307-6868
  • Nufactor: 800-323-6832

Specialty Pharmacy Process

  1. Prescription Transfer: Your current pharmacy must transfer the prescription to an in-network specialty pharmacy
  2. Clinical Support: Specialty pharmacies provide ongoing monitoring, adherence support, and clinical consultation
  3. Delivery Coordination: Secure home delivery or pickup arrangements
  4. Insurance Coordination: Direct billing and prior authorization management
Important: Using an out-of-network pharmacy will result in no coverage, leaving you responsible for Uptravi's full cost (typically $9,000-$25,000 per month).

Support Contacts and Case Management

Provider Support Lines

Primary Contact for PA Questions:

  • Phone: 800-672-7897
  • Services: Prior authorization status, clinical criteria clarification, expedited reviews
  • Hours: 24/7 availability with after-hours voicemail

Specialty Drug Case Management:

  • Clinical Support Line: 888-274-5186 (Prime Therapeutics 24-hour line)
  • Language Assistance: Available through main provider line
  • TDD/TTY: 800-442-7028

Member Services

For Patients:

  • General Member Services: Contact number on your ID card
  • Spanish Language Support: 877-258-3334
  • Appeals Assistance: 855-408-1212 (Smart NC)

Appeals Process for North Carolina

If your initial prior authorization is denied, North Carolina provides a robust appeals process with multiple levels.

Internal Appeals with BCBSNC

Timeline and Process:

  • Providers: Must file within 90 calendar days of denial
  • Members: Have 180 days from denial letter date
  • Submission Methods:
    • Electronic: Blue e provider portal
    • Fax: 919-287-8709 (medical necessity denials)
    • Mail: Blue Cross NC, Provider Appeals Department, PO Box 2291, Durham, NC 27702-2291

External Review Through Smart NC

If internal appeals fail, North Carolina's external review process provides an independent clinical review.

Smart NC External Review:

  • Eligibility: After exhausting internal appeals for medically necessary treatments
  • Timeline: Must file within 120 days of final internal denial
  • Process: Independent Review Organization (IRO) conducts clinical review
  • Decision Timeline: 45 days for standard review, 4 business days for expedited
  • Success Rate: Approximately 50% of specialty drug denials are overturned

Contact Information:

  • Phone: 855-408-1212
  • Fax: 919-807-6865
  • Address: NC Department of Insurance, 1201 Mail Service Center, Raleigh, NC 27699-1201
  • Forms: Available at ncdoi.gov

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient PAH documentation Submit comprehensive hemodynamic data Right heart catheterization results, echo findings
Missing functional assessment Provide WHO Functional Class determination 6-minute walk test, symptom assessment
Lack of background therapy plan Document current/planned combination therapy Treatment timeline, medication list
Drug interaction concerns Address safety profile Medication reconciliation, monitoring plan
Quantity limit exceeded Justify dosing requirements Titration schedule, clinical response data

Medical Necessity Letter Checklist

When appealing a denial, ensure your provider's letter includes:

  • Clinical Problem: Specific PAH diagnosis with WHO Group classification
  • Prior Treatments: Other PAH therapies tried, outcomes, and reasons for discontinuation
  • Clinical Rationale: Why Uptravi is uniquely appropriate for your case
  • Guideline Support: References to FDA labeling and PAH treatment guidelines
  • Monitoring Plan: How treatment response will be assessed and managed

Costs and Patient Assistance

Financial Support Options

Manufacturer Assistance:

  • Janssen offers patient support programs through JNJ WithMe
  • Copay assistance may be available for eligible commercially insured patients
  • Verify eligibility and current programs directly with Janssen

Additional Resources:

  • Patient Advocate Foundation: Financial assistance for chronic conditions
  • Pulmonary Hypertension Association: Support resources and advocacy
  • State pharmaceutical assistance programs (verify North Carolina eligibility)
From Our Advocates: We've seen cases where patients initially faced $15,000+ monthly costs for Uptravi, but after working through the proper PA process and utilizing manufacturer support programs, achieved coverage with manageable copays. The key is thorough documentation and persistence through the appeals process when needed.

FAQ: Uptravi Coverage in North Carolina

How long does BCBSNC prior authorization take? Standard PA decisions are typically made within 3-5 business days. Expedited reviews for urgent cases can be completed within 24 hours when medical necessity is clearly documented.

What if Uptravi is non-formulary on my plan? You can request a formulary exception through the appeals process. Provide documentation showing why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal? Yes, if delaying treatment would seriously jeopardize your health or ability to function. Both BCBSNC internal appeals and Smart NC external reviews offer expedited tracks.

Does step therapy apply if I've tried other PAH medications outside North Carolina? Yes, prior treatment history from other states should be documented and submitted as part of your PA request. Ensure your provider includes comprehensive treatment records.

What happens if Smart NC denies my external review? The IRO decision is binding on the insurance company. If approved, BCBSNC must provide coverage within 3 business days. If denied, you've exhausted administrative remedies, though other legal options may exist.

How often do I need to renew Uptravi authorization? Most BCBSNC plans require annual reauthorization for specialty medications. Your specialty pharmacy will typically coordinate renewal requests before your current authorization expires.

Counterforce Health helps patients and providers navigate complex prior authorization processes like this one. Our platform analyzes denial letters, identifies specific appeal strategies, and generates evidence-backed responses that speak directly to payer policies. By turning insurance obstacles into targeted, clinical arguments, we help ensure patients get access to the medications they need. Learn more about our prior authorization support services at counterforcehealth.org.

When dealing with specialty drug coverage challenges, having the right documentation and following proper procedures makes the difference between approval and denial. North Carolina patients have strong appeal rights through Smart NC, and BCBSNC generally follows evidence-based coverage criteria when properly presented.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current information with your insurance plan and healthcare provider. Consult with qualified professionals for medical decisions and legal matters.

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