By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (selexipag) Covered by Cigna in Texas: Prior Authorization, Appeals, and Cost Assistance

Quick Answer: Getting Uptravi (selexipag) Covered by Cigna in Texas

Cigna requires prior authorization for Uptravi (selexipag) to treat WHO Group I pulmonary arterial hypertension (PAH). You'll need confirmed PAH diagnosis via right heart catheterization, functional class II-IV status, and documentation of prior therapy failures. Submit through your doctor using Cigna's provider portal or CoverMyMeds. Standard approval takes 72 hours; expedited decisions in 24 hours. If denied, you have 180 days to file an internal appeal, followed by external review through Texas Department of Insurance if needed.

First step today: Contact your PAH specialist to gather catheterization results, 6-minute walk tests, and prior therapy documentation, then have them submit the PA request.

Table of Contents

Understanding Uptravi Coverage Requirements

Uptravi (selexipag) is placed on Tier 4 (Brand-Name Specialty) in Cigna's formulary, meaning it carries the highest copay or coinsurance. The medication requires three key approvals: prior authorization (PA), specialty pharmacy dispensing, and quantity limits.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must prove medical necessity Cigna PA form Official PA criteria
Tier 4 Specialty Highest cost-sharing level Plan documents or Cigna member portal Formulary placement
Specialty Pharmacy Must use Accredo or designated SP Insurance card or member services Express Scripts network
Quantity Limits 30-day supply maximum PA approval letter Coverage policy
WHO Group I PAH Confirmed via right heart catheterization Medical records Clinical criteria

Benefit Investigation: What to Ask

Before starting the approval process, gather key information about your specific Cigna plan. Call the member services number on your insurance card and ask:

Essential Questions:

  • "Is Uptravi on my plan's formulary, and what tier?"
  • "What's my specialty drug copay or coinsurance percentage?"
  • "Which specialty pharmacy must I use?"
  • "Does step therapy apply—do I need to try other PAH medications first?"
  • "What's my annual out-of-pocket maximum?"

Document Everything:

  • Representative's name and reference number
  • Date and time of call
  • Specific answers about coverage requirements
  • Any case numbers for follow-up
Tip: If you get conflicting information, ask for the policy details in writing or request to speak with a supervisor.

Cost Assistance Options

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

Manufacturer Support (Commercial Insurance Only)

The Janssen CarePath Oral PAH Savings Program reduces your copay to $5 per prescription with up to $20,000 in annual benefits across eligible oral PAH therapies.

Eligibility Requirements:

  • Commercial or private insurance (not Medicare/Medicaid)
  • US resident, age 18+
  • Not enrolled in SaveOnSP programs

How to Enroll:

  • Visit UPTRAVI.JNJwithMeSavings.com
  • Call 866-228-3546 (Mon-Fri, 8 AM-8 PM ET)
  • Complete enrollment form with your doctor

Patient Assistance Foundations

PAN Foundation: Up to $13,500/year for PAH medication copays (all insurance types). Apply at panapply.org or call 866-316-7263.

HealthWell Foundation: Medicare patients can get help with copays and premiums. Apply through their patient portal or call 800-675-8416.

The Assistance Fund: Accepts waitlist applications for PAH copay assistance. Call 855-649-8623.

Note: Medicare patients cannot use manufacturer copay cards due to federal anti-kickback laws, making foundations especially important for this population.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

Your PAH specialist needs these records:

  • Right heart catheterization confirming WHO Group I PAH
  • Current functional class (II, III, or IV) assessment
  • 6-minute walk test results
  • Documentation of prior PAH therapy trials and outcomes
  • Current medications and contraindications
  • Recent echocardiogram or imaging

Timeline: 1-2 weeks to compile records

2. Submit Prior Authorization (Clinic)

Doctor submits PA through:

  • CoverMyMeds portal
  • Cigna provider portal
  • Fax to precertification number on insurance card
  • Phone line for urgent cases

Timeline: 72 hours for standard decision, 24 hours expedited

3. Enroll in Specialty Pharmacy (Patient)

While PA is pending, enroll with Accredo:

  • Call 877-218-7510
  • Provide insurance information and prescription
  • Set up delivery preferences

Timeline: 2-3 business days for enrollment

4. Activate Cost Assistance (Patient)

If commercially insured, enroll in Janssen CarePath program:

  • Complete forms online or by phone
  • Provide insurance card and prescription information

Timeline: 1-2 business days for activation

5. Monitor PA Status (Patient/Clinic)

Track approval through:

  • Cigna member portal
  • Provider portal (for clinic)
  • Direct calls to precertification department

6. Appeal if Denied (Patient/Clinic)

If denied, immediately request:

  • Peer-to-peer review (doctor-to-doctor discussion)
  • Copy of denial letter with specific reasons
  • Internal appeal submission within 180 days

7. Fill Prescription (Patient)

Once approved:

  • Specialty pharmacy contacts you for delivery
  • Confirm delivery address and timing
  • Set up refill reminders 7-10 days before running out

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not WHO Group I PAH" Submit catheterization report Right heart cath with specific hemodynamic values
"Insufficient functional class" Document current symptoms/limitations 6-minute walk test, NYHA/WHO class assessment
"Step therapy required" Prove prior failures/contraindications Medication history, adverse event documentation
"Quantity exceeds limits" Justify dosing requirements Weight-based calculations, titration schedule
"Not medically necessary" Comprehensive clinical rationale Treatment goals, monitoring plan, guideline citations

Appeals Process in Texas

Texas provides strong patient protection through a two-level internal appeal process followed by independent external review.

Internal Appeals

Level 1 Internal Appeal:

  • Deadline: 180 days from denial notice
  • Decision timeline: 30 days standard, 72 hours expedited
  • Submit via: Cigna member portal, phone (1-800-88CIGNA), or fax (1-866-873-8279)

Required Documents:

  • Original denial letter
  • Medical necessity letter from prescriber
  • Supporting clinical records
  • Insurance card copy

External Review (Texas Department of Insurance)

If internal appeals fail, Texas law provides independent external review:

  • Deadline: 4 months from final internal denial
  • Decision timeline: 20 days standard, 3-5 days expedited
  • Cost: Free to patient (insurer pays)
  • Binding: Cigna must comply with favorable decisions

How to Request:

  • Use Form LHL009 from Texas Department of Insurance
  • Call 1-800-252-3439 for assistance
  • Submit to TDI, which forwards to certified review organization
Important: Self-funded employer plans (ERISA) may not be subject to Texas external review laws. Check your plan documents or ask HR about your specific appeal rights.

Specialty Pharmacy Requirements

Cigna requires Uptravi to be dispensed through designated specialty pharmacies, typically Accredo for most plans.

Why Specialty Pharmacy is Required:

  • Temperature-controlled shipping and storage
  • Clinical monitoring and side effect management
  • Coordination with your care team
  • Insurance billing expertise

What to Expect:

  • Initial consultation with specialty pharmacist
  • Regular check-ins about side effects and adherence
  • Automatic refill coordination
  • Direct delivery to your home

Accredo Contact Information:

  • Phone: 877-218-7510
  • Website: accredo.com
  • Hours: Monday-Friday 8 AM-8 PM, Saturday 8 AM-5 PM (local time)

Counterforce Health helps patients navigate these complex specialty pharmacy requirements by providing templates and tracking tools that ensure proper enrollment and prevent coverage gaps during the approval process.

When Coverage Changes

Insurance benefits can change annually, affecting your Uptravi coverage and costs.

Annual Changes to Monitor

January 1st Plan Updates:

  • Formulary tier changes
  • New prior authorization requirements
  • Specialty pharmacy network changes
  • Copay/coinsurance adjustments

Mid-Year Triggers:

  • Job changes affecting employer coverage
  • Medicare plan switches
  • Medicaid eligibility changes

Renewal Planning

90 Days Before Plan Year End:

  • Review next year's formulary
  • Check for new step therapy requirements
  • Confirm specialty pharmacy network
  • Update cost assistance program enrollment

30 Days Before Current PA Expires:

  • Submit renewal paperwork
  • Update clinical documentation
  • Confirm continued medical necessity
From Our Advocates: We've seen patients successfully maintain coverage by setting calendar reminders 90 days before their plan year ends to review formulary changes. One patient avoided a coverage gap by discovering their new employer plan required different step therapy documentation, giving them time to work with their doctor on the transition.

FAQ

How long does Cigna prior authorization take for Uptravi in Texas? Standard decisions are made within 72 hours. Expedited reviews (for urgent medical situations) are decided within 24 hours. If Cigna doesn't respond within these timeframes, the request is automatically approved.

What if Uptravi is non-formulary on my Cigna plan? You can request a formulary exception with medical justification showing why covered alternatives aren't appropriate for your condition.

Can I get expedited appeals in Texas? Yes, if a delay would seriously jeopardize your health or ability to regain maximum function. Mark all submissions "EXPEDITED" and include a letter from your doctor explaining the urgency.

Does step therapy apply if I've tried medications in another state? Yes, prior therapy documentation from any location counts toward step therapy requirements. Ensure your doctor includes complete medication history with dates, doses, and outcomes.

What happens if I miss doses during the appeals process? Contact your doctor immediately about bridging therapy or samples. Document any treatment gaps for your appeal, as they can strengthen your case for urgent approval.

Can my doctor appeal on my behalf? Yes, healthcare providers can submit appeals for their patients. Many find this more efficient since they have direct access to clinical documentation and can communicate with Cigna's medical directors.

Sources & Further Reading

Counterforce Health specializes in turning insurance denials into successful appeals through evidence-based advocacy. Our platform analyzes denial letters, identifies the specific approval pathway, and generates targeted appeals that align with each insurer's requirements. We help patients, clinicians, and specialty pharmacies navigate complex prior authorization processes for medications like Uptravi, reducing delays and improving approval rates through systematic documentation and payer-specific strategies.

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and your insurance company about specific coverage details. Coverage policies and appeal processes can change; verify current requirements with official sources.

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