By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by Cigna in New Jersey: Prior Authorization, Appeals, and Cost Assistance

Quick Answer: Getting Uptravi Covered by Cigna in New Jersey

Uptravi requires prior authorization from Cigna and is typically dispensed through specialty pharmacy Accredo. Most denials stem from incomplete PAH documentation or missing step therapy trials. Your fastest path: Have your doctor submit Cigna's PA form with complete WHO Group I PAH diagnosis, functional class status, 6-minute walk results, and prior therapy failures. If denied, you have 180 days to appeal internally, then can request New Jersey's free external review through IHCAP. Start today: Call Cigna at the number on your insurance card to confirm PA requirements and get the current forms.

Table of Contents

  1. Understanding Cigna's Uptravi Requirements
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Process in New Jersey
  5. Cost Reduction Strategies
  6. Specialty Pharmacy Coordination
  7. Scripts for Key Conversations
  8. When to Escalate in New Jersey

Understanding Cigna's Uptravi Requirements

Cigna classifies Uptravi (selexipag) as a specialty medication requiring prior authorization and dispensing through their specialty pharmacy partner, Accredo. The drug typically sits on a non-preferred brand tier, meaning higher copays than preferred alternatives.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Doctor must get approval before coverage Cigna PA Policy
Specialty Pharmacy Only Must use Accredo, not retail pharmacy Cigna member portal
Quantity Limits 30-day supply maximum per fill Express Scripts Formulary
Step Therapy May require trying other PAH drugs first Plan-specific formulary
WHO Group I PAH Diagnosis Must have confirmed pulmonary arterial hypertension Clinical documentation

The key to approval is demonstrating that you have WHO Group I pulmonary arterial hypertension with appropriate functional class status and either failed or can't tolerate first-line therapies.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

Your doctor needs comprehensive records showing:

  • Confirmed PAH diagnosis with right heart catheterization results
  • WHO Group I classification (not Groups II-V)
  • Functional Class II-IV status with 6-minute walk test results
  • Prior therapy trials and outcomes (if step therapy applies)
  • Current medications and contraindications to alternatives

Timeline: 1-2 days to compile records

2. Complete Cigna's PA Form (Clinic)

Your prescriber must submit Cigna's prior authorization request with:

  • ICD-10 diagnosis codes for PAH
  • Detailed clinical rationale
  • Dosing plan and titration schedule
  • Supporting lab values and imaging

How to submit: Through Cigna provider portal or fax (verify current number with Cigna) Timeline: Same day submission possible

3. Enroll with Accredo Specialty Pharmacy (Patient + Clinic)

While waiting for PA approval, complete Accredo's enrollment form to expedite dispensing once approved.

Timeline: 24-48 hours for enrollment processing

4. Follow Up on PA Decision (Patient)

Cigna must respond within 72 hours for standard requests, 24 hours for urgent cases.

Action if approved: Coordinate with Accredo for first shipment Action if denied: Review denial letter and proceed to appeals

Tip: Request expedited review if delaying treatment could worsen your PAH symptoms or lead to hospitalization.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Diagnosis not established" Submit complete PAH workup Right heart cath, echo, PFTs, WHO classification
"Step therapy not completed" Document failures/contraindications Prescription history, adverse event notes
"Not medically necessary" Provide clinical evidence Functional class decline, 6MWT results, hospitalization risk
"Quantity exceeds limits" Justify dosing needs Weight-based calculations, titration protocol
"Alternative therapies available" Show why alternatives won't work Drug interaction checks, prior failures, contraindications

Clinician Corner: Medical Necessity Letter Essentials

When crafting your medical necessity letter, include:

  • Problem statement: "Patient has WHO Group I PAH with FC III symptoms despite optimal background therapy"
  • Prior treatments: Specific drugs tried, durations, outcomes, and reasons for discontinuation
  • Clinical rationale: Why Uptravi specifically is needed (mechanism of action, combination therapy rationale)
  • Guideline support: Reference FDA labeling and PAH treatment guidelines
  • Monitoring plan: How you'll track response and manage side effects

Appeals Process in New Jersey

New Jersey provides excellent consumer protection through a two-level internal appeal process followed by free external review.

Internal Appeals with Cigna

First-Level Appeal

  • Deadline: 180 days from denial date
  • How to file: Written request to Cigna appeals department
  • Timeline: 30 days for standard, 72 hours for urgent
  • Include: Original denial letter, additional medical records, updated physician letter

Second-Level Appeal

  • Automatic: If first appeal is denied
  • Timeline: Additional 30 days for Cigna's final decision
  • Reviewer: Different clinical staff than first level

New Jersey External Review (IHCAP)

If Cigna upholds the denial after internal appeals, New Jersey's Independent Health Care Appeals Program (IHCAP) provides free external review.

Eligibility:

  • Completed both internal appeal levels
  • Denial based on medical necessity or similar coverage criteria
  • NJ-regulated insurance plan

How to Apply:

  • Contact: Submit directly to Maximus Federal Services (IHCAP contractor)
  • Deadline: 4 months (180 days) from final internal denial
  • Cost: Free to you (insurer pays all fees)
  • Timeline: Decision within 45 days of complete submission

What to Include:

  • Final denial letter from Cigna
  • All medical records supporting need for Uptravi
  • Physician statement explaining medical necessity
  • Any additional evidence (research studies, treatment guidelines)
From Our Advocates: In our experience, external reviews in New Jersey frequently overturn insurer denials when complete medical documentation is provided. The key is ensuring the reviewing physicians understand why standard alternatives won't work for your specific case—don't assume they're familiar with complex PAH treatment protocols.

Contact Information:

  • IHCAP Hotline: 1-888-393-1062
  • NJ Department of Banking and Insurance: 1-800-446-7467

Cost Reduction Strategies

Uptravi's retail price ranges from $9,000-$25,000 monthly, making cost assistance crucial for most patients.

Manufacturer Copay Program

Janssen CarePath Oral PAH Savings Program:

  • Eligibility: Commercial insurance, age 18+, US/Puerto Rico residents
  • Benefit: Pay as little as $5 per prescription
  • Annual cap: $20,000 maximum program benefit
  • Not eligible: Medicare, Medicaid, or other government insurance
  • How to enroll: Call 1-866-228-3546 or visit Janssen CarePath

For Government Insurance Patients

If you have Medicare or Medicaid, manufacturer copay cards don't apply, but other options exist:

  • Johnson & Johnson Patient Assistance Foundation: May provide free medication for qualifying patients
  • Simplefill: Helps match patients to foundation programs (1-877-386-0206)
  • Medicare Part D 2025 cap: Annual out-of-pocket maximum of $2,000 for all prescriptions

Formulary Exception Requests

If Uptravi is non-formulary or on a high-cost tier, request a formulary exception to move it to a preferred tier with lower copays.

Required documentation:

  • Medical necessity letter explaining why preferred alternatives won't work
  • Prescription history showing failed trials of formulary options
  • Clinical evidence supporting Uptravi specifically

Specialty Pharmacy Coordination

Cigna requires Uptravi dispensing through Accredo specialty pharmacy—it's not available at retail pharmacies.

Working with Accredo

Initial Setup:

  • Complete enrollment form with prescriber
  • Provide insurance information and shipping address
  • Coordinate delivery timing (overnight shipping available)

Ongoing Management:

  • Refills: Accredo contacts you before refills are due
  • Dose changes: Requires new prescription from doctor
  • Prior auth renewals: Accredo helps coordinate with Cigna
  • Clinical support: Pharmacists available for questions about side effects, dosing

Contact: Accredo main number (verify current number on Cigna website)

Note: Accredo manages both the insurance approval process and medication dispensing, making them your primary point of contact once enrolled.

Scripts for Key Conversations

Calling Cigna Member Services

"Hi, I need to understand the prior authorization requirements for Uptravi, spelled U-P-T-R-A-V-I, for pulmonary arterial hypertension. Can you tell me:

  • Is prior auth required for my specific plan?
  • What forms does my doctor need to complete?
  • Are there step therapy requirements?
  • What's the current formulary tier and my copay?
  • How do I request an expedited review if needed?"

Requesting Peer-to-Peer Review (Clinic Staff)

"I'm calling to request a peer-to-peer review for a prior authorization denial for Uptravi. The patient has WHO Group I PAH with functional class III symptoms despite optimal background therapy. Our cardiologist needs to speak with your medical director about why this specific medication is medically necessary. When can we schedule this call?"

Appealing to Accredo for Urgent Fill

"My patient's Uptravi prior auth is pending, but they're running out of medication in 3 days. They have severe PAH and interrupting therapy could lead to clinical deterioration. Can you provide a temporary supply while the PA is being processed? I can provide clinical documentation of the urgent need."

When to Escalate in New Jersey

Contact New Jersey regulators when:

  • Cigna fails to meet response deadlines
  • Appeals process seems unfair or biased
  • You suspect discrimination or bad faith denials

New Jersey Department of Banking and Insurance:

  • Consumer Hotline: 1-800-446-7467
  • Online complaints: NJ DOBI website
  • What to include: Timeline of denials, copies of all correspondence, explanation of harm caused by delays

Federal Options (for Medicare Advantage plans):

  • Medicare.gov complaints: For MA plan issues
  • CMS: If you suspect systematic denial patterns

FAQ

How long does Cigna prior authorization take in New Jersey? Standard PA decisions are due within 72 hours; urgent requests within 24 hours. If Cigna misses deadlines, you can file a complaint with NJ DOBI.

What if Uptravi isn't on my Cigna formulary? Request a formulary exception with medical necessity documentation. If denied, appeal through internal process then external review.

Can I get expedited appeals in New Jersey? Yes, both Cigna and NJ's external review process offer expedited timelines when delays could seriously harm your health.

Does step therapy apply if I tried medications outside New Jersey? Yes, prescription records from any state count toward step therapy requirements. Provide complete pharmacy records to your doctor.

What happens if I lose Cigna coverage mid-year? Contact Janssen CarePath immediately—they may provide temporary medication while you transition to new insurance.

Can my doctor file the external review for me? Yes, New Jersey allows providers to file IHCAP appeals on behalf of patients with written consent.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed responses. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements, pulling the right clinical evidence and operational details to support your case.

For complex cases like Uptravi appeals, having professional support can significantly improve your chances of approval. Counterforce Health specializes in navigating payer-specific workflows and procedural requirements while tracking deadlines and ensuring all necessary documentation is included.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage and appeal procedures can change. Always verify current requirements with your insurance company and consult your healthcare provider about treatment decisions. For personalized assistance with insurance appeals in New Jersey, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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