By Counterforce Health Team in Uptravi (selexipag) —

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

Answer Box: Quick Path to Uptravi Coverage

To get Uptravi (selexipag) covered by Humana in Pennsylvania, you need prior authorization with specific documentation. Most approvals require: confirmed WHO Group I PAH by right heart catheterization, documented failure of at least two other PAH therapies, and a specialist's prior authorization form. If denied, Pennsylvania's new external review process has a 50% overturn rate. Start today: Contact your pulmonologist or cardiologist to begin gathering hemodynamic data and prior therapy records, then submit Humana's PA form online or by fax.

Table of Contents

  1. Eligibility Quick Check
  2. Required Documentation Checklist
  3. Step-by-Step Approval Process
  4. Common Denial Reasons & Solutions
  5. Pennsylvania Appeals Process
  6. Cost-Saving Options
  7. When to Escalate
  8. FAQ

Eligibility Quick Check

Use this decision tree to determine your likely approval chances:

✅ Likely Eligible

  • Confirmed WHO Group I PAH by right heart catheterization (mean PA pressure >20 mmHg, wedge pressure ≤15 mmHg)
  • Functional Class II, III, or IV symptoms
  • Documented failure of at least two other PAH therapies (ERAs, PDE5 inhibitors, or other prostacyclin pathway drugs)
  • Specialist prescriber (pulmonologist or cardiologist)

Next step: Proceed to documentation checklist below.

⚠️ Possibly Eligible

  • PAH diagnosis but missing hemodynamic confirmation
  • Only tried one prior PAH therapy
  • Functional status not clearly documented
  • Primary care prescriber (may need specialist referral)

Next step: Schedule specialist consultation and request missing tests.

❌ Not Yet Eligible

  • No confirmed PAH diagnosis
  • Haven't tried standard first-line therapies
  • WHO Group II-V pulmonary hypertension
  • Contraindications to selexipag (gemfibrozil use, PVOD)

Next step: Discuss alternative treatments with your physician or request exception based on medical necessity.

Required Documentation Checklist

Before submitting your prior authorization, gather these documents:

Clinical Documentation

  • Right heart catheterization report showing WHO Group I PAH hemodynamics
  • Echocardiogram and other imaging studies
  • 6-minute walk test results (if available)
  • Functional class assessment (WHO Class II-IV)
  • Current medication list including all PAH therapies

Prior Therapy Records

  • Documentation of at least two failed PAH therapies with:
    • Drug names and doses tried
    • Duration of each trial
    • Reasons for discontinuation (ineffective, side effects, contraindications)
    • Dates of therapy

Prescriber Requirements

  • Specialist signature (pulmonologist or cardiologist required)
  • Medical necessity letter explaining why Uptravi is appropriate
  • Treatment plan including monitoring strategy
Clinician Corner: Your medical necessity letter should specifically address why alternative therapies failed or are contraindicated, reference current PAH treatment guidelines, and explain how Uptravi fits into the patient's overall treatment strategy. Include current functional status and treatment goals.

Step-by-Step Approval Process

Step 1: Specialist Consultation

Who: Patient schedules with pulmonologist or cardiologist
Timeline: 2-4 weeks for appointment
Action: Ensure all diagnostic testing is current and complete

Step 2: Gather Documentation

Who: Clinical staff coordinates records
Timeline: 1-2 weeks
Action: Collect all items from checklist above

Step 3: Submit Prior Authorization

Who: Prescriber or their staff
How: Humana provider portal or fax
Timeline: Submit all materials at once to avoid delays
Forms: Use Humana's specific PA form for Uptravi

Step 4: Await Decision

Standard Review: Up to 30 days
Expedited Review: 72 hours (if health is at risk)
Tracking: Check status via Humana member portal or provider system

Step 5: If Approved

Action: Fill prescription through Humana's specialty pharmacy network
Cost: Verify copay and any manufacturer assistance programs

Step 6: If Denied

Timeline: You have 65 days to appeal
Action: Proceed to appeals process below

Common Denial Reasons & Solutions

Denial Reason How to Fix Required Evidence
Insufficient prior therapy Document additional failed treatments Pharmacy records, physician notes showing trials of ≥2 PAH drug classes
Missing hemodynamic data Provide right heart catheterization Report showing mPAP >20 mmHg, PCWP ≤15 mmHg
Wrong prescriber type Get specialist to resubmit Pulmonologist or cardiologist signature required
Incomplete medical necessity Strengthen clinical rationale Detailed letter explaining why alternatives won't work
Drug interactions not addressed Address contraindications Document screening for CYP2C8 inhibitors, especially gemfibrozil

Pennsylvania Appeals Process

Pennsylvania offers multiple appeal levels with strong patient protections:

Level 1: Internal Appeal (Redetermination)

  • Timeline: File within 65 days of denial
  • Process: Submit written request to Humana
  • Decision: 7 days for Part D appeals
  • Success rate: Varies by case complexity

Level 2: Independent External Review

Pennsylvania's new state-run program launched in 2024 offers significant advantages:

  • Eligibility: Must complete internal appeal first
  • Timeline: 4 months to file after final denial
  • Process: Submit via Pennsylvania Insurance Department portal
  • Decision: 45 days (72 hours for expedited cases)
  • Success rate: Approximately 50% of appeals overturned in 2024
  • Cost: Free to patients

How to File:

  1. Complete internal appeal and receive Final Adverse Benefit Determination
  2. Submit external review request online with supporting documents
  3. You have 15 days after assignment to submit additional evidence
  4. Independent medical reviewers make binding decision
From our advocates: We've seen cases where patients initially denied for Uptravi were approved on external review after submitting additional hemodynamic data and a stronger medical necessity letter. The key was demonstrating that the patient had truly failed other therapies and showing clear functional impairment. While outcomes vary, Pennsylvania's new process gives patients a real second chance.

Level 3: Further Appeals

If external review is unsuccessful, additional federal appeal levels may be available depending on your specific plan type.

Cost-Saving Options

Uptravi can cost $9,000-$25,000 per month without insurance. Consider these assistance programs:

Manufacturer Support

  • Janssen CarePath: May offer copay assistance for eligible patients
  • Patient assistance programs: For uninsured or underinsured patients
  • Verify eligibility: Contact manufacturer directly for current programs

Foundation Grants

  • Patient Advocate Foundation: Copay relief for chronic diseases
  • HealthWell Foundation: May have PAH-specific funds
  • Application required: Most have income and insurance requirements

State Programs

  • Pennsylvania PACE/PACENET: Prescription assistance for seniors
  • Medicaid: May provide coverage if you qualify

When to Escalate

Contact Pennsylvania regulators if you experience:

  • Unreasonable delays beyond standard timeframes
  • Repeated denials without clear medical rationale
  • Process violations (missing deadlines, inadequate review)

Pennsylvania Insurance Department Consumer Services:

Frequently Asked Questions

Q: How long does Humana prior authorization take in Pennsylvania? A: Standard review takes up to 30 days, expedited review takes 72 hours. Pennsylvania law doesn't change these federal timelines, but the state's external review adds an additional appeal option.

Q: What if Uptravi isn't on Humana's formulary? A: You can request a formulary exception along with your prior authorization. This requires additional documentation showing why formulary alternatives aren't appropriate.

Q: Can I get expedited review? A: Yes, if waiting for standard review could seriously harm your health. Your doctor must document the urgency and submit supporting clinical evidence.

Q: Does step therapy apply if I've tried PAH drugs outside Pennsylvania? A: Yes, prior therapy trials from any location count toward step therapy requirements. Ensure you have documentation from all previous providers.

Q: What happens if I pay out-of-pocket during an appeal? A: If your appeal is successful, Humana must provide retroactive coverage and reimburse your costs. Keep all receipts and documentation.

Q: Can my primary care doctor prescribe Uptravi? A: Humana requires a pulmonologist or cardiologist to prescribe Uptravi. You'll need a specialist referral if you don't already have one.

Q: How do I know if I have WHO Group I PAH? A: This requires right heart catheterization showing specific pressure measurements. Echocardiogram estimates aren't sufficient for Humana approval.

Q: What if I'm taking gemfibrozil? A: This is an absolute contraindication to Uptravi. Your doctor would need to find an alternative cholesterol medication before Uptravi could be considered.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements.

Getting Uptravi covered by Humana in Pennsylvania requires careful preparation and documentation, but the state's new external review process provides meaningful recourse if you're initially denied. By following this systematic approach and leveraging Pennsylvania's patient-friendly appeal system, you can maximize your chances of accessing this important PAH therapy.

For additional help with your specific case, consider working with Counterforce Health or contacting Pennsylvania's consumer assistance programs for personalized guidance through the appeals process.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical situation and treatment options. Insurance policies and appeal processes can change; verify current requirements with your insurer and state regulators.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.