By Counterforce Health Team in Uptravi (selexipag) —

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

Quick Answer: Getting Uptravi Covered by Humana in Georgia

Humana requires prior authorization for Uptravi (selexipag) for pulmonary arterial hypertension. Your fastest path: Have your PAH specialist submit documentation showing WHO Group I PAH diagnosis, functional class II-IV status, and trials of two prior PAH drug classes. If denied, you have 65 days to appeal internally, then 65 days for external review through Georgia's Department of Insurance. Start today: Call your prescriber to begin the prior authorization process and gather your hemodynamic data, 6-minute walk test results, and prior therapy records.

Table of Contents

  1. Why Georgia Rules Matter for Humana Coverage
  2. Prior Authorization Requirements
  3. Step Therapy Protections in Georgia
  4. Appeals Timeline and Process
  5. External Review Through Georgia DOI
  6. Common Denial Reasons and Solutions
  7. Practical Scripts and Templates
  8. Cost Considerations and Support
  9. When to Escalate to State Regulators
  10. Frequently Asked Questions

Why Georgia Rules Matter for Humana Coverage

Georgia's insurance laws provide crucial protections that work alongside Humana's Medicare Advantage and Part D policies. For Uptravi (selexipag), a specialty PAH medication costing $9,000-$25,000 monthly, understanding both federal Medicare rules and Georgia's specific consumer protections can make the difference between approval and denial.

Key Georgia Protections:

  • Step therapy exceptions under Georgia Code § 33-24-59.25 when drugs are contraindicated or previously failed
  • External review rights through the Georgia Department of Insurance within 60 days of final denial
  • Expedited review (72 hours) when delays pose serious health risks
  • Consumer assistance through the DOI's Consumer Services Division at 1-800-656-2298
Note: Humana's Medicare plans follow federal CMS guidelines, but Georgia's external review process provides an additional layer of protection for wrongful denials.

Prior Authorization Requirements

Humana lists Uptravi on their 2025 Medicare prior authorization list as a Tier 5 specialty drug. Your prescriber must demonstrate medical necessity through specific clinical criteria.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing Humana 2025 PA List
Formulary Tier Tier 5 (Specialty) MyHumana Drug List
Step Therapy 2+ prior PAH drug classes Humana pharmacy policy
Specialist Required Pulmonologist or cardiologist PA form requirement
Diagnosis Code WHO Group I PAH (I27.0) ICD-10 requirement

Required Documentation

Clinical Evidence Needed:

  1. Confirmed PAH Diagnosis: Right heart catheterization showing mean pulmonary artery pressure ≥25 mmHg and pulmonary capillary wedge pressure <15 mmHg
  2. Functional Assessment: WHO functional class II, III, or IV status with 6-minute walk test results
  3. Prior Therapy Trials: Documentation of at least two PAH drug classes tried for 60+ days each, including:
    • Specific medications, doses, and duration
    • Reasons for discontinuation (ineffective, intolerance, contraindications)
    • Current background therapy plan
  4. Specialist Prescription: From pulmonologist or cardiologist experienced in PAH management

Step Therapy Protections in Georgia

Georgia law requires health plans to grant step therapy exceptions when specific criteria are met. This is particularly relevant for PAH patients who may have contraindications to first-line therapies.

Exception Criteria Under Georgia Code § 33-24-59.25:

  • The prescribed drug is contraindicated
  • The patient experienced adverse reactions to required step therapy drugs
  • The patient previously tried and failed the step therapy medication
  • The prescriber believes the step therapy drug will be ineffective
Tip: When requesting a step therapy override, have your prescriber explicitly reference Georgia Code § 33-24-59.25 and provide detailed documentation of why first-line therapies are inappropriate.

Medical Exception Documentation

Your prescriber should include:

  • Contraindication details: Specific drug interactions or medical conditions
  • Prior failure evidence: Previous trial dates, doses, and documented lack of efficacy
  • Clinical rationale: Why Uptravi is medically necessary as first-line therapy
  • Monitoring plan: How response will be assessed and safety monitored

Appeals Timeline and Process

Understanding Humana's appeals process in Georgia is crucial, as Medicare Advantage plans follow federal timelines while Georgia provides additional external review rights.

Medicare Advantage Appeals Timeline

Level Action Filing Deadline Decision Timeline
Level 1 Humana Reconsideration 65 days from denial Pre-service: 30 days
Expedited: 72 hours
Level 2 Independent Review Entity 65 days from Level 1 denial Standard: 30 days
Expedited: 72 hours
Level 3 OMHA Hearing 60 days from IRE denial 90-180 days

Key Deadlines:

  • Internal Appeal: Submit within 65 days of initial denial notice
  • Expedited Review: Available when standard timing could seriously jeopardize health
  • Required Documentation: Original denial letter, clinical records, claim information
Important: Track deadlines carefully. Late submissions require "good cause" explanations and may be rejected.

External Review Through Georgia DOI

Georgia's Department of Insurance provides external review for Medicare Advantage denials that meet specific criteria. This process is free and conducted by independent medical experts.

How to File External Review

Eligibility Requirements:

  • Completed Humana's internal appeal process
  • Denial based on medical necessity, experimental/investigational determination, or utilization review
  • Request submitted within 60 days of final internal denial

Filing Process:

  1. Gather Documents: Final denial letter, medical records, prescriber statement
  2. Submit Request: Via Georgia DOI Consumer Portal or call 1-800-656-2298
  3. Independent Review: Qualified physicians in pulmonology review your case
  4. Binding Decision: Humana must comply with favorable external review decisions

Expedited External Review: Available within 72 hours when your physician certifies that delay poses serious health risks. You can request expedited external review even while internal appeals are pending in urgent situations.

Common Denial Reasons and Solutions

Based on Humana's pharmacy policies and Medicare guidelines, here are typical denial reasons for Uptravi and how to address them:

Denial Reason Solution Strategy Required Documentation
Insufficient PAH documentation Submit complete hemodynamic data Right heart catheterization report with specific pressure measurements
Missing step therapy Document prior drug trials or contraindications Pharmacy records, prescriber notes on failures/intolerances
Non-specialist prescriber Transfer care or obtain consultation Referral to pulmonologist or cardiologist
Inadequate functional assessment Provide current status evaluation 6-minute walk test, WHO functional class assessment
Drug interaction concerns Address safety monitoring plan Medication reconciliation, monitoring protocol

Practical Scripts and Templates

Patient Phone Script for Humana

"Hi, I'm calling about a prior authorization denial for Uptravi, reference number [denial #]. My doctor says this medication is medically necessary for my pulmonary arterial hypertension because [specific reason]. I'd like to request an expedited internal appeal and speak with a clinical reviewer. Can you help me understand what additional documentation you need?"

Clinician Letter Template

Medical Necessity Elements to Include:

  • Patient's specific PAH diagnosis with hemodynamic confirmation
  • Current functional class and exercise capacity
  • Detailed history of prior PAH therapies with specific outcomes
  • Clinical rationale for Uptravi based on mechanism of action
  • Monitoring plan and expected treatment goals
  • Reference to current PAH guidelines supporting prostacyclin pathway therapy

Cost Considerations and Support

Uptravi's high cost makes coverage approval critical. Understanding your options can help manage expenses while pursuing authorization.

Financial Support Options:

  • Medicare Part D Coverage: 2025 out-of-pocket maximum is $2,000; 2026 maximum increases to $2,100
  • Janssen CarePath: Manufacturer patient assistance program (verify eligibility at Janssen CarePath)
  • Specialty Pharmacy Networks: Humana may require specific pharmacy partners for specialty drugs
From our advocates: We've seen patients successfully appeal Uptravi denials by working closely with their PAH specialist to document specific functional improvements needed for daily activities. One effective approach involved submitting detailed 6-minute walk test trends showing decline without prostacyclin pathway therapy, combined with a clear monitoring plan for dose titration.

When to Escalate to State Regulators

If Humana's internal processes fail or you encounter procedural violations, Georgia's Department of Insurance can intervene.

Contact Georgia DOI When:

  • Appeals deadlines aren't met by Humana
  • Required forms or processes aren't followed
  • Denials appear to violate Georgia step therapy laws
  • You need assistance navigating the external review process

Georgia DOI Consumer Services:

Working with Counterforce Health

When facing complex prior authorization challenges, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific denial basis, then drafts point-by-point rebuttals aligned with Humana's own coverage criteria. For PAH medications like Uptravi, we help gather the right clinical evidence and regulatory citations to strengthen your case.

Frequently Asked Questions

How long does Humana prior authorization take for Uptravi in Georgia? Standard prior authorization decisions take up to 30 days for pre-service requests. Expedited reviews are completed within 72 hours when delay could harm your health.

What if Uptravi is non-formulary on my Humana plan? You can request a formulary exception with medical necessity documentation. Your prescriber must demonstrate why formulary alternatives are inappropriate for your condition.

Can I request an expedited appeal if my PAH is worsening? Yes. If your physician certifies that standard timing could seriously jeopardize your health, both internal appeals and external reviews can be expedited to 72 hours.

Does Georgia's step therapy law apply to Medicare plans? Georgia step therapy protections apply to fully insured plans regulated by the state. Medicare Advantage plans follow federal guidelines, but you can still reference Georgia law when requesting medical exceptions.

What happens if I miss the 65-day appeal deadline? You can request "good cause" consideration by explaining why the deadline was missed. Valid reasons include serious illness, lack of notice, or administrative errors by the plan.

How do I find a PAH specialist for my prior authorization? Contact Humana's provider directory or ask for referrals through your primary care physician. Pulmonologists and cardiologists with PAH experience are most qualified to prescribe Uptravi.

Can I continue current PAH therapy while appealing? If you're already on Uptravi and face a coverage change, request continuity of care coverage. For new prescriptions, discuss bridging therapy options with your prescriber.

What if my appeal is denied at all levels? After exhausting Medicare appeals (including federal court if the amount exceeds $1,840), you may have additional options through Georgia consumer protection laws or legal assistance.

Sources and 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 plan details. Always consult with your healthcare provider about treatment options and contact Counterforce Health or qualified professionals for assistance with complex prior authorization challenges. For official guidance, contact Humana directly or the Georgia Department of Insurance Consumer Services Division at 1-800-656-2298.

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