By Counterforce Health Team in Uptravi (selexipag) —

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

Answer Box: Getting Uptravi Covered by Humana in Michigan

Uptravi (selexipag) requires prior authorization from Humana Medicare Advantage plans in Michigan. To get approved: (1) Have your pulmonologist or cardiologist gather right heart catheterization results confirming WHO Group I PAH and document two failed prior PAH therapies, (2) Submit Humana's Medicare Prescription Drug Coverage Determination form via fax to 877-486-2621, and (3) If denied, file an appeal within 65 days or request Michigan DIFS external review within 127 days for commercial plans. Start today by calling your specialist to request your catheterization report and prior therapy records.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You're Asked for More Information
  7. If Your Request Is Denied
  8. Appeals Process in Michigan
  9. Renewal and Reauthorization
  10. Common Denial Reasons and How to Fix Them
  11. Costs and Financial Assistance
  12. Quick Reference Checklist
  13. FAQ

What This Guide Covers

This comprehensive guide helps patients with pulmonary arterial hypertension (PAH) and their healthcare teams navigate Humana's prior authorization process for Uptravi (selexipag) in Michigan. Whether you have Humana Medicare Advantage or a commercial plan, we'll walk you through every step from initial submission to appeals if needed.

Uptravi is an oral prostacyclin receptor agonist that helps delay disease progression and reduce PAH-related hospitalizations. With retail prices ranging from $9,000 to $25,000 per month, getting insurance approval is essential for most patients.

Who This Guide Helps:

  • Patients prescribed Uptravi for WHO Group I PAH
  • Caregivers managing insurance appeals
  • Clinicians submitting prior authorizations
  • Anyone facing a Humana denial for PAH medications

Before You Start: Verify Your Coverage

Step 1: Confirm Your Plan Type

Check your insurance card to determine if you have:

  • Humana Medicare Advantage with Part D (most common)
  • Humana commercial individual or group plan
  • Humana Medicaid plan

This matters because appeal rights and timelines differ between plan types.

Step 2: Verify Uptravi's Formulary Status

Uptravi appears on Humana's 2024 Medicare Advantage Medication Preauthorization List, confirming prior authorization is required. The medication is typically classified as Tier 5 specialty, meaning higher copays apply.

Step 3: Confirm Your Prescriber

Humana generally requires Uptravi to be prescribed by or in consultation with a pulmonologist or cardiologist experienced in PAH management. If your current prescriber isn't a specialist, you'll need a referral or consultation.

Gather What You Need

Essential Clinical Documentation

Right Heart Catheterization Report

  • Mean pulmonary arterial pressure ≥25 mmHg (or >20 mmHg per newer criteria)
  • Pulmonary capillary wedge pressure ≤15 mmHg
  • Pulmonary vascular resistance >2-3 Wood units
  • Explicit confirmation of WHO Group I PAH diagnosis

WHO Functional Class Assessment

  • Current functional class (II, III, or IV)
  • 6-minute walk test results if available
  • Description of current symptoms and limitations

Prior Therapy Documentation Humana requires evidence of inadequate response, intolerance, or contraindication to at least two other PAH drug classes, each tried for approximately 60 days:

  • PDE5 inhibitors (sildenafil/Revatio, tadalafil/Adcirca)
  • Endothelin receptor antagonists (ambrisentan, bosentan, macitentan)
  • Soluble guanylate cyclase stimulators (riociguat/Adempas)

For each prior therapy, document:

  • Drug name, dose, and duration
  • Start and stop dates
  • Reason for discontinuation (ineffective, side effects, contraindication)

Administrative Requirements

  • Insurance card and member ID
  • Prescriber DEA and NPI numbers
  • ICD-10 code for pulmonary arterial hypertension
  • Current medication list
  • Recent lab results and imaging reports

Submit the Prior Authorization Request

For Humana Medicare Advantage Plans

Form Required: Request for Medicare Prescription Drug Coverage Determination

Submission Methods:

  • Fax: 877-486-2621 (verify with the source linked below)
  • Online: Humana provider portal or member portal
  • Electronic: Through CoverMyMeds or Availity platforms

Step-by-Step Submission Process

  1. Complete the PA form with all required fields
  2. Attach supporting documentation:
    • Right heart catheterization report
    • Medical necessity letter from specialist
    • Prior therapy documentation
    • Current clinical notes showing WHO functional class
  3. Submit via your preferred method
  4. Confirm receipt and obtain reference number
  5. Document submission date for timeline tracking
Tip: Submit requests early in the week to avoid weekend delays, and always keep copies of everything you send.

Follow-Up and Timelines

Standard Review Timelines

  • Medicare Advantage/Part D: Up to 30 calendar days for standard review
  • Expedited review: 72 hours if delay could seriously jeopardize health
  • Commercial plans: Varies by state regulations (typically 15-30 days)

When to Follow Up

Call Humana if you haven't heard back within:

  • 5 business days for expedited requests
  • 15 business days for standard requests

Sample Follow-Up Script: "I'm calling to check on prior authorization request #[reference number] for Uptravi submitted on [date]. Can you provide a status update and expected decision date?"

If You're Asked for More Information

Humana may request additional documentation. Common requests include:

Missing Clinical Data

  • Complete hemodynamic measurements from catheterization
  • Detailed prior therapy history with specific dates and outcomes
  • Current functional assessment with 6-minute walk test

Medical Necessity Clarification

  • More detailed explanation of why formulary alternatives are inappropriate
  • Specialist consultation notes
  • Recent hospitalizations or disease progression documentation

Respond to information requests within 14 days to avoid automatic denial.

If Your Request Is Denied

Understanding Denial Reasons

Common denial codes include:

  • Step therapy not met: Insufficient documentation of prior therapy failures
  • Not medically necessary: Clinical criteria not adequately demonstrated
  • Non-formulary: Drug not on preferred medication list

Immediate Steps After Denial

  1. Review the denial letter carefully for specific reasons
  2. Gather additional documentation to address cited deficiencies
  3. Contact your prescriber to discuss appeal strategy
  4. File appeal within required timeframe (65 days for Medicare, varies for commercial)
From Our Advocates: We've seen many initial denials overturned when providers submit comprehensive catheterization reports showing clear WHO Group I PAH diagnosis alongside detailed prior therapy documentation. The key is addressing each specific criterion mentioned in the denial letter rather than submitting generic appeals.

Appeals Process in Michigan

For Humana Medicare Advantage Plans

Level 1: Internal Appeal (Redetermination)

  • Deadline: 65 days from denial notice
  • Timeline: 7 days for standard, 72 hours for expedited
  • How to file: Same form used for initial request, marked as "appeal"

Level 2: Independent Review Entity

  • Automatically forwarded if Level 1 is unsuccessful
  • Independent medical review by Maximus or similar entity
  • Timeline: 7-14 days for decision

For Humana Commercial Plans in Michigan

Internal Appeal

  • Follow Humana's internal grievance process first
  • Obtain final adverse determination in writing

Michigan DIFS External Review

Expedited External Review Criteria:

  • Delay would seriously jeopardize life or health
  • Physician substantiation required (oral or written)
  • Decision within 72 hours of DIFS receipt

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by creating targeted, evidence-backed letters that address each plan's specific criteria. Our platform analyzes denial reasons and generates point-by-point rebuttals using the right clinical evidence and payer-specific requirements.

Key Michigan Appeal Resources

  • DIFS Consumer Hotline: 877-999-6442
  • External Review Information: Michigan DIFS Appeals Process
  • Forms: Available on DIFS website or by calling the hotline

Renewal and Reauthorization

When to Start Renewal Process

Begin reauthorization 60-90 days before your current approval expires. Most Humana approvals last 12 months.

Documentation for Renewal

  • Evidence of clinical benefit:
    • Stable or improved WHO functional class
    • Maintained or improved 6-minute walk distance
    • Reduced PAH-related hospitalizations
    • Absence of intolerable side effects
  • Updated clinical notes showing current status
  • Confirmation of continued specialist care
  • Current medication adherence documentation

Common Denial Reasons and How to Fix Them

Denial Reason Required Documentation How to Submit
Insufficient step therapy Detailed prior therapy history with dates, doses, and outcomes for ≥2 PAH drug classes Medical records, pharmacy records, prior PA approvals
Missing hemodynamic data Complete right heart catheterization report with all pressure measurements Original cath lab report or cardiology consultation note
Non-specialist prescriber Consultation or prescription from pulmonologist/cardiologist Specialist consultation note or prescription transfer
Inadequate medical necessity Comprehensive letter explaining why Uptravi is specifically needed Medical necessity letter citing current PAH guidelines

Costs and Financial Assistance

Expected Costs with Humana

  • Tier 5 specialty copay: Varies by plan (typically 25-33% coinsurance)
  • 2024 Part D deductible: $0-$590 depending on plan
  • Catastrophic coverage: 100% covered after $2,100 out-of-pocket annually

Financial Assistance Options

Manufacturer Support:

  • Limited for Medicare patients due to federal regulations
  • May be available for commercial insurance gaps

Independent Foundations:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Chronic Disease Fund
Note: Medicare patients have restrictions on manufacturer copay assistance, but independent charitable foundations may help with out-of-pocket costs.

Quick Reference Checklist

Before Submitting: □ Right heart catheterization report with hemodynamics □ WHO Group I PAH diagnosis confirmed □ Documentation of ≥2 failed prior PAH therapies □ Current WHO functional class assessment □ Specialist prescriber (pulmonologist/cardiologist) □ Completed PA form with all required fields

After Submission: □ Confirmation of receipt and reference number □ Calendar follow-up date (15 days for standard, 5 for expedited) □ Copies of all submitted documents □ Plan for potential appeal if denied

If Denied: □ Review denial letter for specific reasons □ Gather additional documentation to address deficiencies □ File appeal within deadline (65 days Medicare, 127 days Michigan commercial) □ Consider expedited appeal if clinically urgent

FAQ

How long does Humana prior authorization take for Uptravi in Michigan? Standard review takes up to 30 days for Medicare plans. Expedited review is completed within 72 hours when delay could jeopardize health. Commercial plan timelines vary but typically range from 15-30 days.

What if Uptravi is non-formulary on my Humana plan? You can request a formulary exception along with your prior authorization. This requires demonstrating that all formulary alternatives are medically inappropriate for your specific condition.

Can I request an expedited appeal if my condition is worsening? Yes. For Medicare plans, expedited appeals are available when delay could seriously jeopardize life or health. For Michigan commercial plans, DIFS offers 72-hour expedited external review with physician substantiation.

Does step therapy apply if I failed PAH medications outside Michigan? Yes. Prior therapy documentation from any location is acceptable as long as you can provide adequate records showing drug names, doses, duration, and reasons for discontinuation.

What happens if I can't afford the copay after approval? Explore independent charitable foundations that may help with copays. Medicare patients have limited access to manufacturer assistance programs due to federal anti-kickback regulations.

How do I know if my appeal was successful? Humana must provide written notification of all coverage decisions. For external reviews through Michigan DIFS, you'll receive a written decision that's binding on the insurer.

For complex denials or appeals, Counterforce Health specializes in creating evidence-backed appeal letters that address payer-specific requirements and significantly improve approval rates for specialty medications like Uptravi.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with your insurance plan and consult with your healthcare provider for medical decisions. For assistance with insurance appeals and coverage issues in Michigan, contact the Michigan Department of Insurance and Financial Services at 877-999-6442.

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