By Counterforce Health Team in Uptravi (selexipag) —

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

Answer Box: Getting Started Today

To get Uptravi (selexipag) covered by Humana in New Jersey: (1) Confirm WHO Group I PAH diagnosis with right heart catheterization data, (2) Document WHO Functional Class II-IV and failed trials of at least two PAH drug classes, (3) Submit prior authorization via Humana's provider portal or fax to 877-486-2621. If denied, you have 65 days to appeal internally, then can file external review through New Jersey's IHCAP program within 4 months. Start today: Gather your catheterization report and current medication list.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Documentation Packet Essentials
  5. Submission Process
  6. Specialty Pharmacy Routing
  7. After Submission: What to Expect
  8. Appeals Process in New Jersey
  9. Common Denial Reasons & How to Fix Them
  10. Cost Assistance Options
  11. FAQ

Who Should Use This Guide

This guide helps patients with pulmonary arterial hypertension (PAH) and their healthcare providers navigate Humana's prior authorization process for Uptravi (selexipag) in New Jersey. You'll need this if:

  • Your doctor prescribed Uptravi for WHO Group I PAH
  • You have Humana Medicare Advantage with Part D coverage
  • Your pharmacy informed you that prior authorization is required
  • You received a denial and need to appeal

Expected outcome: With complete documentation, most Humana PA requests for appropriate PAH patients receive approval within 15-30 days. If initially denied, appeals have strong success rates when clinical criteria are met—Medicare Advantage appeals overall see 82% reversal rates for appropriate requests.

Member & Plan Basics

Coverage Requirements

Requirement Details How to Verify
Active Humana Coverage Medicare Advantage with Part D Check member ID card or MyHumana portal
Formulary Status Tier 5 specialty drug Humana drug list search
Prior Authorization Required for all strengths Provider PA search tool
Specialty Pharmacy CenterWell preferred CenterWell information
Note: Humana's PA denial rate for Medicare Advantage is approximately 3.5%—among the lowest of major insurers—but denials often stem from incomplete documentation rather than clinical inappropriateness.

Clinical Criteria Requirements

Essential Documentation for Medical Necessity

1. Confirmed WHO Group I PAH Diagnosis

  • Right heart catheterization showing:
    • Mean pulmonary artery pressure ≥25 mmHg
    • Pulmonary capillary wedge pressure <15 mmHg
    • Pulmonary vascular resistance ≥3 Wood units
  • Workup excluding Groups 2-5 (left heart disease, lung disease, chronic thromboembolic PH)

2. WHO Functional Class Assessment Document exact functional class with supporting symptoms:

  • Class II: Slight limitation; ordinary activity causes dyspnea/fatigue
  • Class III: Marked limitation; less than ordinary activity causes symptoms
  • Class IV: Symptoms at rest or with any activity

3. Step Therapy Requirements Must document trials (≥60 days each) or contraindications to at least two PAH drug classes:

  • Endothelin receptor antagonists (ambrisentan, bosentan)
  • PDE-5 inhibitors (sildenafil, tadalafil)
  • Include specific drugs, doses, dates, and reasons for discontinuation

4. Risk Stratification Data

  • 6-minute walk distance (if available)
  • NT-proBNP or BNP levels
  • Recent echocardiogram (RV function, estimated PAP)
  • PAH-related hospitalizations in past year

Prescriber Requirements

  • Pulmonologist or cardiologist with PAH experience
  • Affiliation with specialized pulmonary hypertension center preferred

Documentation Packet Essentials

Provider Note Elements

Your clinical note should include:

  1. Clear PAH diagnosis: "WHO Group I idiopathic PAH, confirmed by RHC on [date]"
  2. Functional status: "Current WHO FC III based on dyspnea with minimal exertion"
  3. Treatment history: Specific prior PAH medications with dates and outcomes
  4. Current clinical status: Recent symptoms, hospitalizations, objective measures
  5. Treatment rationale: Why Uptravi is appropriate at this time

Medical Necessity Letter Components

Clinician Corner: Your letter should address:Patient's specific PAH diagnosis and hemodynamic dataCurrent WHO functional class with supporting symptomsPrior therapy failures or contraindications with specific detailsClinical rationale citing FDA labeling or PAH guidelinesExpected monitoring plan and treatment goals

Required Attachments

  • Right heart catheterization report
  • Recent clinic notes (within 6 months)
  • Medication history with specific dates and doses
  • Laboratory results (BNP, liver function if relevant)
  • Echocardiogram report (if recent)

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Office)
    • Confirm active Humana MA Part D coverage
    • Check formulary status using drug list tool
  2. Gather Documentation (Clinic)
    • Collect all required clinical documents listed above
    • Ensure right heart cath report is available
  3. Complete PA Form (Prescriber)
    • Use "Request for Medicare Prescription Drug Coverage Determination"
    • Include all required clinical information
  4. Submit Request (Clinic)
    • Preferred: Humana provider portal
    • Alternative: Fax to 877-486-2621
    • Emergency: Call for expedited review if medically urgent
  5. Track Status (Patient/Office)
    • Standard review: 15-30 days
    • Expedited: 72 hours if urgent medical need
  6. Follow Up (Office)
    • Check portal for status updates
    • Respond promptly to requests for additional information

Common Submission Errors to Avoid

  • Missing right heart catheterization data
  • Incomplete step therapy documentation
  • Vague functional class assessment
  • No prescriber specialty information
  • Outdated clinical information (>6 months)

Specialty Pharmacy Routing

CenterWell Specialty Pharmacy Process

Once PA is approved, Humana directs Uptravi fills to CenterWell Specialty Pharmacy:

  1. Initial Setup: CenterWell contacts patient to verify insurance and shipping address
  2. Clinical Review: Pharmacist reviews therapy and provides education
  3. Shipment: Medication ships via temperature-controlled delivery
  4. Ongoing Support: Regular refill coordination and clinical monitoring

Prescription Transfer Steps

If switching from another pharmacy:

  • Request transfer through Humana provider portal
  • Include PA reference number
  • CenterWell handles transfer logistics
  • Verify shipping address and preferences

After Submission: What to Expect

Timeline and Status Tracking

Timeframe What Happens How to Check
1-3 days Initial review, acknowledgment Provider portal, confirmation email
5-10 days Clinical review begins Portal status updates
15-30 days Final determination Written notice to patient and provider
72 hours Expedited decisions (if urgent) Phone/portal notification

What to Record

  • Confirmation number from submission
  • Date of submission
  • Reviewer name (if peer-to-peer occurs)
  • Any additional information requests
  • Final determination date and reference number

Appeals Process in New Jersey

Internal Appeals with Humana

Timeline: 65 days from denial notice Process:

  1. Complete Humana appeal form (included with denial letter)
  2. Include additional clinical documentation addressing denial reasons
  3. Submit via provider portal or mail to address on denial notice
  4. Request expedited review if medically urgent (72-hour decision)

External Review Through IHCAP

If internal appeal fails, New Jersey offers external review through the Independent Health Care Appeals Program (IHCAP):

Eligibility: Must complete Humana's internal appeals first Timeline: File within 4 months of final denial Process: Submit via Maximus NJIHCAP portal Review Time: 45 days standard, 72 hours expedited Cost: No charge to patient

Important: New Jersey's external review process is administered by Maximus Federal Services. The decision is binding on Humana if you win.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Key Documents
Insufficient PAH documentation Submit complete right heart cath report with hemodynamic data RHC report, echo, clinical notes
Step therapy not met Document specific prior therapies with dates, doses, and failure reasons Medication history, provider notes
Inappropriate functional class Provide detailed symptom assessment matching WHO FC definitions 6-minute walk test, clinical assessment
Missing prescriber credentials Confirm pulmonologist/cardiologist specialty in submission Provider CV, hospital affiliation
Outdated clinical information Submit recent clinical data within 6 months Updated clinic notes, recent labs

Cost Assistance Options

Patient Support Programs

  • Janssen CarePath: Provides coverage support and patient education (Medicare patients have limited manufacturer assistance)
  • Independent Foundations: Patient Advocate Foundation, HealthWell Foundation (verify current PAH programs)
  • State Programs: New Jersey pharmaceutical assistance programs (income-based eligibility)

Medicare Part D Considerations

  • Coverage gap ("donut hole") may apply
  • Low Income Subsidy (Extra Help) can reduce costs significantly
  • Annual out-of-pocket maximum provides cost protection

FAQ

How long does Humana prior authorization take in New Jersey? Standard review takes 15-30 days. Expedited review for urgent medical needs takes 72 hours. Humana is committed to providing decisions within one business day for 95% of complete electronic PA requests by 2026.

What if Uptravi is non-formulary on my plan? You can request a formulary exception through the same PA process. Include documentation showing medical necessity and that preferred alternatives are inappropriate.

Can I request an expedited appeal? Yes, if a delay would seriously jeopardize your health. Contact Humana directly and provide clinical justification for urgency.

Does step therapy apply if I failed therapies outside New Jersey? Yes, step therapy documentation from any location is acceptable as long as you can provide adequate records of the trials and outcomes.

What happens if IHCAP overturns Humana's denial? Humana must authorize and pay for the service within 10 business days of the IHCAP decision. The decision is legally binding.

How much does Uptravi cost with Humana coverage? As a Tier 5 specialty drug, your copay depends on your specific plan. Costs typically range from $47-$150+ per month, with coverage gap considerations.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each plan's specific requirements, pulling the right citations and clinical facts to support medical necessity arguments.

For additional support with complex prior authorization cases, Counterforce Health provides specialized assistance in crafting appeals that address payer-specific requirements and procedural timelines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider regarding treatment decisions and contact Humana directly for the most current coverage policies. For questions about New Jersey insurance regulations, contact the NJ Department of Banking and Insurance at 1-800-446-7467.

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