By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by Humana in Ohio: Prior Authorization Guide with Appeals Process

Quick Answer: Getting Uptravi (Selexipag) Covered by Humana in Ohio

Your fastest path to approval: Submit a prior authorization request with documented WHO Group I PAH diagnosis, functional class II-IV status, 6-minute walk test results, and evidence of background therapy plan. If denied, you have 65 days to appeal with supporting medical necessity documentation. Ohio residents get external review through the Ohio Department of Insurance within 180 days of final denial.

Start today: Call Humana at 800-867-6601 to confirm Uptravi's formulary status and request prior authorization forms, or access them through your member portal at Humana.com.

Table of Contents

  1. Why Ohio State Rules Matter for Your Humana Coverage
  2. Humana Prior Authorization Requirements for Uptravi
  3. Step Therapy Protections Under Ohio Law
  4. Appeals Process: Internal and External Review
  5. Continuity of Care During Coverage Transitions
  6. Practical Scripts and Documentation Tips
  7. When to Contact Ohio Regulators
  8. FAQ: Common Questions About Uptravi Coverage

Why Ohio State Rules Matter for Your Humana Coverage

Ohio's insurance laws provide important protections that work alongside your Humana Medicare Advantage plan policies. While Medicare sets baseline standards, Ohio adds consumer-friendly layers that can help you get specialty medications like Uptravi (selexipag) approved more efficiently.

Key Ohio protections include:

  • Step therapy exemptions under Ohio Revised Code § 3901.83 with 72-hour review timelines for non-urgent cases
  • External review rights through the Ohio Department of Insurance within 180 days of final denial
  • Continuity of care protections during plan transitions, including up to 90 days of extended coverage

For Humana Medicare Advantage members, these state protections complement federal Medicare appeal rights, giving you multiple pathways to challenge denials.

Humana Prior Authorization Requirements for Uptravi

Uptravi (selexipag) typically requires prior authorization from Humana due to its specialty tier placement and high cost (~$9,000–$25,000 per month). Here's what Humana generally requires:

Medical Necessity Documentation

Your prescriber must submit evidence of:

  • Confirmed WHO Group I PAH diagnosis with supporting hemodynamic data
  • Functional Class II, III, or IV status documented within the past 6 months
  • 6-minute walk test results showing distance and any limitations
  • Background therapy plan or evidence of combination therapy appropriateness
  • Prior treatment history including failures, intolerances, or contraindications to formulary alternatives

Common Denial Reasons and Solutions

Denial Reason Required Documentation Where to Find It
Insufficient PAH documentation Right heart catheterization results, WHO Group I confirmation Cardiology or pulmonology records
Missing functional class 6-minute walk test, NYHA/WHO functional assessment Recent clinic visit notes
No background therapy justification Treatment plan showing combination appropriateness Prescriber treatment notes
Drug interactions not addressed Medication reconciliation, safety assessment Pharmacy consultation notes

Submission Process

Standard timeline: Humana provides decisions within 72 hours of receiving complete prescriber documentation for formulary exceptions.

Submit via:

Step Therapy Protections Under Ohio Law

Ohio law provides specific protections if Humana requires you to try other PAH medications before approving Uptravi. Under Ohio Revised Code § 3901.83, you can request a step therapy exemption if:

Exemption Criteria

  • Previous failure: You've tried the required medication and it was ineffective or caused adverse effects
  • Prior approval: Uptravi was approved by Humana in the current or previous year
  • Life-threatening condition: PAH qualifies as a progressive, life-threatening disease
  • Medical necessity: Your prescriber documents that prerequisite drugs would be less effective or cause harm

How to Request an Exception

Timeline: Health plans must review step therapy exception requests within 72 hours for non-urgent cases (24 hours if urgent).

Documentation needed:

  • Prescriber attestation of previous drug failures or contraindications
  • Clinical evidence supporting immediate access to Uptravi
  • Reference to Ohio law § 3901.83 in your request

Sample language for your prescriber: "Based on this patient's documented failure of [specific PAH medication] and contraindications to [other formulary options], I request a step therapy exemption under Ohio Revised Code § 3901.83 for immediate access to Uptravi (selexipag)."

Appeals Process: Internal and External Review

If Humana denies your Uptravi prior authorization, Ohio provides a structured appeals process with specific timelines and protections.

Internal Appeals (Redetermination)

Timeline: You have 65 days from Humana's denial notice to file an appeal. Humana must respond within 7 calendar days for Part D medication appeals.

Expedited appeals: Available when waiting could seriously harm your health. Decision required within 72 hours if approved for expedited review.

Required information:

  • Your name, address, and Medicare number
  • Specific drug being appealed (Uptravi/selexipag)
  • Detailed medical necessity justification
  • Prescriber supporting statement
  • Any new clinical evidence

External Review Through Ohio

If Humana upholds the denial, Ohio residents have 180 days to request external review through the Ohio Department of Insurance.

Process:

  1. File request with the Ohio Department of Insurance at 1-800-686-1526
  2. Independent Review Organization (IRO) assignment within days
  3. Decision timeline: 30 days for standard review, 72 hours for expedited
  4. Binding result: If overturned, Humana must cover Uptravi

What to include:

  • External Review Request Form (verify current form with ODI)
  • All denial letters and medical records
  • Prescriber statement supporting medical necessity
  • Peer-reviewed literature supporting Uptravi use for your condition

Continuity of Care During Coverage Transitions

Ohio law requires health plans to maintain continuity of care processes during coverage transitions. This is particularly important for expensive specialty medications like Uptravi.

Automatic Protections

Ohio continuity laws provide up to 90 days of extended in-network benefits for ongoing specialty treatments when:

  • Your prescriber leaves Humana's network
  • You change to a different Humana plan
  • You meet criteria for serious/complex conditions requiring specialized care

Grace Period Protections

While specific grace periods for PAH medications aren't detailed in available Ohio regulations, Ohio's House Bill 220 prohibits retroactive denials of prior authorization except in limited circumstances, protecting ongoing therapy.

If you're switching plans: Contact your new plan immediately to request a continuity of care review and temporary coverage while prior authorization is processed.

Practical Scripts and Documentation Tips

Phone Script for Humana Customer Service

"I'm calling about prior authorization for Uptravi, generic name selexipag, for pulmonary arterial hypertension. I need to confirm the current formulary status and get the prior authorization requirements. Can you also tell me if there are step therapy requirements and how to request an exception under Ohio law if needed?"

Medical Necessity Letter Checklist for Prescribers

Essential elements to include:

  • Diagnosis: WHO Group I PAH with ICD-10 code I27.0
  • Functional status: Current WHO/NYHA functional class with supporting test results
  • Prior therapies: Specific medications tried, duration, outcomes, and reasons for discontinuation
  • Clinical rationale: Why Uptravi is medically necessary vs. formulary alternatives
  • Monitoring plan: How treatment response will be assessed
  • Guideline support: Reference to FDA labeling or PAH treatment guidelines

Documentation Gathering Checklist

Before starting your appeal:

  • ✓ Insurance card and member ID
  • ✓ Complete denial letter from Humana
  • ✓ Right heart catheterization results
  • ✓ Recent 6-minute walk test
  • ✓ Medication history with specific drugs, doses, and outcomes
  • ✓ Current lab results (BNP, liver function if relevant)
  • ✓ Prescriber contact information

When to Contact Ohio Regulators

Contact the Ohio Department of Insurance if:

  • Humana refuses to process your appeal within required timelines
  • You're told external review isn't available when you believe it should be
  • There are procedural violations in the appeals process
  • You need help understanding your rights under Ohio law

Ohio Department of Insurance Consumer Services: 1-800-686-1526

What to have ready:

  • Your complete case file including all denials and appeals
  • Documentation of any procedural issues or missed deadlines
  • Clear description of the medical necessity for Uptravi

Getting prescription drugs approved by insurance can feel overwhelming, especially for complex conditions like pulmonary arterial hypertension. At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed documentation that aligns with each plan's specific requirements. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals, pulling the right clinical evidence and procedural requirements to improve approval rates and reduce back-and-forth with payers.

FAQ: Common Questions About Uptravi Coverage

How long does Humana prior authorization take for Uptravi in Ohio? Standard decisions are made within 72 hours of receiving complete prescriber documentation. Expedited reviews (when waiting could harm your health) are decided within 72 hours of approval for expedited status.

What if Uptravi isn't on Humana's formulary? You can request a formulary exception by having your prescriber submit documentation that covered alternatives are less effective or would cause adverse effects. The same 72-hour timeline applies.

Can I get an expedited appeal for Uptravi? Yes, if your prescriber documents that waiting for a standard 7-day appeal decision could seriously harm your health. Humana must provide expedited decisions within 72 hours when medically justified.

Does Ohio step therapy law apply to Medicare Advantage plans? Ohio's step therapy protections under § 3901.83 apply to state-regulated plans. While Medicare Advantage follows federal rules, citing Ohio law in your exception request can strengthen your case and demonstrates awareness of medical necessity standards.

What happens if I lose my external review in Ohio? The Independent Review Organization's decision is binding on Humana, but you retain other legal remedies. You can also file complaints with federal Medicare authorities or pursue other dispute resolution options.

How much does Uptravi cost without insurance? Retail prices typically range from $9,000–$25,000 per month depending on strength. Janssen offers patient assistance programs—check their official website for current eligibility criteria and applications.

Can I stay on Uptravi if I switch from Humana to another plan? Ohio's continuity of care laws provide some protection during transitions. Contact your new plan immediately to request temporary coverage while prior authorization is processed, and mention Ohio's continuity requirements.

What if my doctor leaves Humana's network while I'm on Uptravi? Ohio law provides up to 90 days of continued in-network benefits for ongoing specialty treatments when providers leave networks, giving you time to transition care or find a new in-network PAH specialist.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical or legal advice. Insurance coverage decisions depend on your specific plan terms, medical history, and individual circumstances. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for current coverage information. For personalized help with your appeal, consider working with Counterforce Health or other patient advocacy services.

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