By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by Humana in California: Complete Prior Authorization and Appeal Guide

Answer Box: Getting Uptravi (Selexipag) Covered by Humana in California

Humana requires prior authorization for Uptravi (selexipag) for pulmonary arterial hypertension (PAH). To get approved: 1) Have your PAH specialist complete Humana's prior authorization form with WHO Group I PAH diagnosis via right heart catheterization, 2) Document trials/failures of at least two other PAH drug classes, and 3) Submit within 65 days if denied. California residents have additional appeal rights through Independent Medical Review (IMR) with 55-65% reversal rates for specialty drug denials.

First step today: Contact your prescriber to gather hemodynamic data and prior therapy documentation for the PA submission.

Table of Contents

Humana's Coverage Requirements

Humana places Uptravi (selexipag) on its Medicare Advantage preauthorization list for 2024, requiring prior authorization before coverage. Here's what Humana looks for:

Coverage at a Glance

Requirement What It Means Documentation Needed
Prior Authorization Must be approved before dispensing Completed PA form from specialist
WHO Group I PAH Diagnosis Confirmed by right heart catheterization Hemodynamic data: mPAP ≥25 mmHg, PCWP <15 mmHg
Step Therapy Try preferred drugs first Records of 2+ PAH drug class failures (60+ days each)
Specialist Requirement Pulmonologist or cardiologist Prescription from or consultation with PAH specialist
Formulary Tier Tier 5 (specialty) Higher copay/coinsurance applies

Key Clinical Criteria

Based on typical insurer requirements for PAH medications, Humana generally requires:

  • Confirmed WHO Group I PAH with right heart catheterization showing mean pulmonary artery pressure ≥25 mmHg and pulmonary capillary wedge pressure <15 mmHg
  • Trial and failure or contraindication to at least two different oral PAH drug classes:
    • PDE-5 inhibitors (sildenafil/Revatio, tadalafil/Adcirca)
    • Endothelin receptor antagonists (ambrisentan/Letairis, bosentan/Tracleer, macitentan/Opsumit)
    • Guanylate cyclase stimulators (riociguat/Adempas)
  • No concurrent prostacyclin therapy (to avoid drug interactions)
  • Functional Class II-IV symptoms documented

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

Timeline: 1-2 days
What you need:

  • Right heart catheterization results
  • Complete list of prior PAH medications with dates, doses, and reasons for discontinuation
  • Current functional class assessment
  • 6-minute walk test results (if available)

2. Specialist Completes Prior Authorization Form (Clinic)

Timeline: 2-3 business days
How to submit: Via Humana's provider portal or fax (verify current fax number)
Required: Licensed pulmonologist or cardiologist must complete and sign the form

3. Humana Reviews Submission (Humana)

Timeline: Up to 30 days for standard review, 72 hours for expedited
What happens: Clinical pharmacists review against formulary criteria and medical necessity guidelines

4. Receive Decision (Patient)

Timeline: Written notice within decision timeframe
Next steps: If approved, prescription can be filled. If denied, you have 65 days to appeal.

Tip: Request expedited review if your health could be seriously harmed by waiting. This reduces the timeline to 72 hours.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documentation to Add
Insufficient prior therapy documentation Submit detailed trial history Pharmacy records, physician notes showing dates, doses, and reasons for discontinuation
Missing hemodynamic confirmation Provide right heart cath results Complete catheterization report with pressures and resistance calculations
No specialist involvement Get pulmonologist/cardiologist to prescribe Referral letter or consultation note from PAH specialist
Drug-drug interaction concerns Address interaction management Plan for monitoring or alternative dosing strategy
Quantity limits exceeded Justify higher dose medically Clinical rationale for dose escalation based on patient response

Appeals Process: Humana to California IMR

If Humana denies your Uptravi request, California residents have robust appeal rights through a two-tier system.

Level 1: Humana Internal Appeal (Redetermination)

  • Deadline: 65 days from denial notice
  • Timeline: 7 days for standard appeals, 72 hours for expedited
  • How to file: Humana member portal or mail/fax
  • Required: Written statement explaining why the denial should be overturned, plus supporting clinical documentation

Level 2: Independent Review Entity (IRE)

  • Deadline: 60 days from redetermination decision
  • Timeline: 7 days for decision
  • Process: Federal contractor reviews case independently of Humana

California Independent Medical Review (IMR)

For HMO plans regulated by California's Department of Managed Health Care (DMHC), you can request an Independent Medical Review after exhausting internal appeals.

Note: California's IMR process has particularly strong success rates for rare disease medications like PAH therapies when proper clinical evidence is provided.

Medical Necessity Documentation Checklist

For Your Prescriber to Include:

Clinical History:

  • WHO Group I PAH diagnosis with ICD-10 code (I27.0 or I27.2)
  • Right heart catheterization results with specific pressures
  • Current WHO functional class (II, III, or IV)
  • 6-minute walk test distance (if performed)

Prior Therapy Documentation:

  • Complete medication history with:
    • Drug names and doses
    • Start and stop dates
    • Reason for discontinuation (ineffective, intolerant, contraindicated)
    • Duration of each trial (minimum 60 days typically required)

Treatment Plan:

  • Uptravi dosing strategy (starting at 200 mcg twice daily, titrating to maximum tolerated dose)
  • Monitoring plan for side effects
  • Goals of therapy (delay disease progression, reduce hospitalizations)

Supporting Evidence to Reference:

California-Specific Appeal Rights

California provides some of the strongest patient protection laws in the country for insurance appeals:

Department of Managed Health Care (DMHC) Oversight

  • Regulates most HMOs and managed care plans
  • Help Center: 888-466-2219
  • Online IMR application: healthhelp.ca.gov
  • No cost to patients for IMR requests

California Department of Insurance (CDI)

  • Regulates some PPO and indemnity plans
  • Consumer Hotline: 800-927-4357
  • Similar external review process available

Key California Protections:

  • Step therapy override rights when medically necessary
  • Timely access regulations for specialty medications
  • Independent medical experts review appeals (not insurance company employees)
  • Binding decisions that insurers must follow

When preparing for California IMR, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to plan policies.

Cost Support Options

Manufacturer Programs

  • Janssen withMe Program: Provides support for Uptravi access and affordability
  • Note: Medicare beneficiaries are not eligible for manufacturer copay assistance

Foundation Support

  • Pulmonary Hypertension Association (PHA) maintains a list of patient assistance programs
  • Disease-specific foundations may offer emergency financial assistance

State Programs

  • California's Medicaid (Medi-Cal) expansion provides coverage for eligible low-income patients
  • Covered California marketplace plans must cover essential health benefits including prescription drugs

FAQ

How long does Humana prior authorization take for Uptravi in California? Standard reviews take up to 30 days, but expedited reviews are completed within 72 hours if you can demonstrate that waiting could seriously harm your health.

What if Uptravi is not on Humana's formulary? You can request a formulary exception by demonstrating medical necessity. The same documentation requirements apply, plus you'll need to show why formulary alternatives are inappropriate.

Can I request an expedited appeal in California? Yes, both Humana and California's IMR process offer expedited reviews for urgent medical situations. Expedited IMRs are decided within 7 days or less.

Does step therapy apply if I failed PAH medications outside California? Yes, prior therapy failures from any location count toward meeting step therapy requirements, as long as they're properly documented in your medical records.

What's the success rate for Uptravi appeals in California? While specific drug success rates aren't published, California's IMR process reverses 55-65% of specialty drug denials when proper clinical evidence is provided.

How do I know if my Humana plan is regulated by DMHC or CDI? Most Humana Medicare Advantage plans fall under federal regulation, but any commercial HMO plans would be DMHC-regulated. Check your member handbook or call Humana customer service.

From Our Advocates

We've seen PAH patients succeed in their Uptravi appeals when they work closely with their specialist to document not just the diagnosis, but the complete story of their treatment journey. One key factor is timing—don't wait until you're out of medication to start the appeal process. The strongest cases include detailed pharmacy records showing exactly how long each prior therapy was tried and specific reasons why it didn't work, whether that was persistent symptoms, intolerable side effects, or drug interactions.

Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with payer-specific requirements and pull the right clinical evidence for medications like Uptravi.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and specific plan terms. Always consult with your healthcare provider and insurance plan for guidance specific to your situation. For assistance with California insurance complaints or appeals, contact the DMHC Help Center at 888-466-2219 or visit healthhelp.ca.gov.

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