By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by Cigna in Illinois: Appeal Guide with Forms and Timelines

Answer Box: Getting Uptravi (Selexipag) Covered by Cigna in Illinois

Cigna requires prior authorization for Uptravi (selexipag) for pulmonary arterial hypertension (PAH). Your doctor must submit clinical documentation proving WHO Group 1 PAH diagnosis with functional class II-III symptoms and prior therapy trials. If denied, you have 180 days for internal appeals and 30 days after final denial for Illinois external review. Start today: Have your doctor call Cigna at 1-800-882-4462 to initiate prior authorization or request a peer-to-peer review if already denied.

Table of Contents

  1. Understanding Cigna's Prior Authorization Requirements
  2. Reading Your Denial Letter
  3. Common Denial Reasons and Quick Fixes
  4. Step-by-Step: Fastest Path to Approval
  5. First-Level Internal Appeal
  6. Peer-to-Peer Review Strategy
  7. Illinois External Review Process
  8. Medical Necessity Letter Essentials
  9. Appeal Templates and Scripts
  10. Cost-Saving Options
  11. When to Escalate to State Regulators
  12. Frequently Asked Questions

Understanding Cigna's Prior Authorization Requirements

Cigna manages specialty drugs like Uptravi through Express Scripts/Accredo specialty pharmacy. Before covering Uptravi (selexipag), Cigna requires your doctor to prove several clinical criteria are met.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
WHO Group 1 PAH diagnosis Confirmed pulmonary arterial hypertension via right-heart catheterization mPAP >25 mmHg, PAWP ≤15 mmHg, PVR >3 Wood units Cigna PAH Policy
Functional Class II-III Moderate activity limitation NYHA/WHO functional class assessment FDA Label
Prior therapy requirement Failed or inadequate response to background PAH therapy Documentation of PDE-5 inhibitor AND endothelin receptor antagonist trials Cigna PAH Policy
Specialist oversight Care managed by PAH specialist Cardiologist or pulmonologist with PAH expertise Express Scripts Guidelines

Cigna aims to respond to prior authorization requests within 72 hours for non-urgent cases and 24 hours for urgent situations.

Reading Your Denial Letter

When Cigna denies Uptravi coverage, your denial letter will include specific reason codes. Understanding these helps you craft a targeted appeal.

Common denial codes include:

  • Medical necessity not established - Missing clinical documentation
  • Step therapy required - Must try other PAH medications first
  • Non-formulary - Drug not on preferred list
  • Quantity limits exceeded - Requesting more than standard dosing
  • Provider not authorized - Prescriber lacks specialty credentials

Look for the appeal deadline prominently displayed—typically 180 days from the denial date for Cigna internal appeals.

Common Denial Reasons and Quick Fixes

Denial Reason How to Fix Documents Needed
"Diagnosis not confirmed" Submit right-heart catheterization report Hemodynamic data showing PAH criteria
"Prior therapy not documented" Provide medication history records Prescription records, clinic notes showing PDE-5i/ERA trials
"Functional class unclear" Submit current functional assessment NYHA Class II-III documentation, 6-minute walk test
"Prescriber not qualified" Request specialist referral Cardiologist/pulmonologist consultation notes
"Step therapy not completed" Document failures/contraindications Adverse event reports, efficacy failure notes

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

  • Insurance card and member ID
  • Right-heart catheterization report
  • Current functional class assessment
  • Prior PAH medication trials and outcomes
  • Recent 6-minute walk test results

2. Initiate Prior Authorization (Clinic Staff)

Call Cigna at 1-800-882-4462 or submit via provider portal. Expected timeline: 72 hours for standard review.

3. If Denied, Request Peer-to-Peer (Prescriber)

Schedule within 5 business days of denial. Have PAH specialist speak directly with Cigna medical director.

4. File Internal Appeal (Patient/Clinic)

Submit within 180 days via Cigna member portal or mail. Include all supporting documentation.

5. Request Illinois External Review (Patient)

If internal appeal fails, file with Illinois Department of Insurance within 30 days of final denial.

6. Track All Deadlines

Use a calendar system to monitor response times and next steps.

7. Consider Alternatives

Explore manufacturer assistance programs or formulary alternatives while appeals proceed.

First-Level Internal Appeal

Your internal appeal should address the specific denial reason with clinical evidence. Include:

Required Components:

  • Member information and policy number
  • Original denial letter
  • Prescriber's letter of medical necessity
  • Supporting clinical documentation
  • Request for coverage determination reversal

Submission Options:

  • Cigna member portal (fastest)
  • Mail to address on denial letter
  • Fax (verify current number with customer service)

Timeline: Cigna must respond within 15 business days for pre-service requests.

Peer-to-Peer Review Strategy

A peer-to-peer review allows your PAH specialist to speak directly with Cigna's medical director. This often resolves denials faster than written appeals.

Preparation Checklist:

  • Schedule within 5 business days of denial
  • Have PAH specialist (not primary care) make the call
  • Prepare 3-5 key talking points about medical necessity
  • Reference specific sections of Cigna's PAH policy
  • Emphasize functional decline risk without treatment

Key Talking Points:

  1. Confirmed WHO Group 1 PAH with hemodynamic data
  2. Functional Class II-III with documented exercise limitation
  3. Inadequate response to combination PDE-5i/ERA therapy
  4. Risk of disease progression without prostacyclin pathway therapy
  5. Patient's specific contraindications to alternative treatments

Illinois External Review Process

If Cigna upholds their denial after internal appeals, Illinois law guarantees your right to an independent external review by a physician specialist.

Key Illinois Requirements:

  • File within 30 days of final adverse determination
  • No cost to patients
  • Independent Review Organization (IRO) assigns board-certified physician
  • Decision within 5 business days once IRO receives records
  • Binding decision on Cigna if overturned

How to File:

  1. Complete external review form at Illinois DOI website
  2. Include final denial letter from Cigna
  3. Attach all medical records and supporting documentation
  4. Submit within 30-day deadline

For Help: Call Illinois Department of Insurance at 877-527-9431 or Illinois Attorney General's Health Care Helpline at 1-877-305-5145.

From Our Advocates: We've seen external reviews succeed when the IRO physician reviewer specializes in pulmonary hypertension and can evaluate whether Cigna's denial contradicts established PAH treatment guidelines. The key is submitting comprehensive hemodynamic data and functional assessments that clearly document disease severity.

Medical Necessity Letter Essentials

Your prescriber's letter of medical necessity should follow this structure:

1. Patient Problem Statement

  • Confirmed WHO Group 1 PAH diagnosis with hemodynamic data
  • Current functional class (II-III) with specific limitations
  • Disease progression risk without treatment

2. Prior Treatment History

  • PDE-5 inhibitor trial (sildenafil/tadalafil) with outcomes
  • Endothelin receptor antagonist trial (ambrisentan/bosentan) with outcomes
  • Reasons for inadequate response or intolerance

3. Clinical Rationale for Uptravi

  • FDA-approved indication for PAH progression delay
  • GRIPHON trial evidence showing 40% reduction in PAH progression
  • Patient's specific need for prostacyclin pathway therapy

4. Monitoring Plan

  • Functional class assessments every 3 months
  • 6-minute walk distance tracking
  • Titration schedule and safety monitoring

Appeal Templates and Scripts

Patient Phone Script for Cigna Customer Service

"Hello, I'm calling about a prior authorization denial for Uptravi, generic name selexipag, for pulmonary arterial hypertension. My member ID is [number]. I'd like to request a peer-to-peer review with your medical director and information about filing an internal appeal. Can you connect me with utilization management?"

Clinic Staff Peer-to-Peer Request Script

"I'm calling to request a peer-to-peer review for [patient name], member ID [number], for Uptravi denial reference [number]. Dr. [name] is a pulmonary hypertension specialist and needs to discuss the medical necessity with your reviewing physician. What's your earliest availability?"

Email Template for Medical Records

"Subject: Urgent - Medical Records Needed for Uptravi Appeal

We need the following records for [patient name] to support their Uptravi appeal to Cigna:

  • Right-heart catheterization report from [date]
  • Functional class assessments from past 6 months
  • Prior PAH medication trial documentation
  • Recent 6-minute walk test results

Please send to [fax/email] by [date] to meet appeal deadline. Thank you."

Cost-Saving Options

While pursuing appeals, explore these cost assistance programs:

Manufacturer Support:

  • Uptravi Copay Program: May reduce out-of-pocket costs for eligible patients
  • Patient assistance programs for uninsured/underinsured

Foundation Grants:

  • Pulmonary Hypertension Association assistance programs
  • HealthWell Foundation grants for PAH medications
  • Patient Access Network Foundation specialty drug support

State Programs:

  • Illinois pharmaceutical assistance programs (verify eligibility)
  • Medicaid coverage if income-eligible

When to Escalate to State Regulators

Contact Illinois regulators if:

  • Cigna misses response deadlines
  • Appeals process violations occur
  • Pattern of inappropriate denials suspected

Illinois Department of Insurance:

  • Consumer hotline: 877-527-9431
  • File complaints about insurer practices
  • Enforce external review decisions

Illinois Attorney General Health Care Bureau:

  • Helpline: 1-877-305-5145
  • Informal intervention with insurers
  • Consumer protection enforcement

Counterforce Health specializes in turning insurance denials into successful, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters, identifying the specific denial basis, and crafting targeted rebuttals aligned with each plan's own policies. For medications like Uptravi, we pull the right clinical evidence—from FDA labeling to peer-reviewed PAH studies—and weave them into appeals that meet payer-specific procedural requirements.

Frequently Asked Questions

How long does Cigna prior authorization take for Uptravi in Illinois? Cigna aims for 72-hour responses for non-urgent requests and 24 hours for urgent cases. If they don't respond within these timeframes, the request is automatically approved.

What if Uptravi is non-formulary on my Cigna plan? Request a formulary exception through your doctor. Provide clinical justification for why formulary alternatives are inappropriate for your specific case.

Can I request expedited appeals in Illinois? Yes, if treatment delay would seriously jeopardize your health. Illinois law requires expedited decisions within 24-48 hours for urgent cases.

Does step therapy apply if I tried PAH medications outside Illinois? Medical records from any state should count toward step therapy requirements. Ensure your new Illinois provider has complete documentation of prior trials.

What happens if my external review is approved? Cigna must cover the treatment. The external review decision is binding on the insurer.

How much does Uptravi cost without insurance? Retail prices typically range $9,000-$25,000 for a 30-day supply, depending on strength. Manufacturer copay programs may reduce costs for eligible patients.

Can I appeal if my doctor isn't a PAH specialist? Yes, but consider getting a consultation with a cardiologist or pulmonologist who specializes in PAH, as specialist oversight often strengthens appeals.

What if I miss the appeal deadline? Contact Counterforce Health or Illinois consumer assistance programs immediately. Some exceptions may apply for good cause, but act quickly.

Disclaimer: This information is for educational purposes only and not medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact qualified legal counsel for specific legal questions.

Sources & Further Reading

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