By Counterforce Health Team in Uptravi (selexipag) —

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

Answer Box: Getting Uptravi (Selexipag) Covered by Humana in Washington

Humana requires prior authorization for Uptravi (selexipag) under Medicare Advantage plans. To get approved: (1) Have your pulmonologist or cardiologist submit a complete prior authorization with hemodynamic confirmation of WHO Group I PAH, documentation of failed step therapy with at least two other PAH drug classes, and a detailed medical necessity letter, (2) If denied, file an internal appeal within 65 days, then request Washington state's Independent Review Organization (IRO) external review within 60 days of final denial, (3) Start today by gathering right heart catheterization results, prior therapy records, and current functional class documentation. Washington's external review process has strong consumer protections with binding decisions in 20-45 days.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Documentation Requirements
  5. Submission Process
  6. Common Denial Reasons & Solutions
  7. Appeals Process for Washington Residents
  8. Cost Considerations
  9. When to Escalate
  10. Quick Reference Checklist

Who Should Use This Guide

This guide is for Washington residents with Humana Medicare Advantage coverage who need Uptravi (selexipag) for pulmonary arterial hypertension (PAH). You'll benefit most if you:

  • Have confirmed WHO Group I PAH diagnosis
  • Are currently symptomatic despite other treatments
  • Have tried or cannot tolerate standard PAH therapies
  • Need help navigating Humana's prior authorization process

Expected outcome: With complete documentation, most PAH patients meeting clinical criteria get approved on initial submission. If denied, Washington's strong external review process overturns approximately 40% of insurance denials.

Member & Plan Basics

Active Coverage Requirements

Verify your Humana Medicare Advantage plan is active and includes prescription drug coverage (Part D). Uptravi is classified as a Tier 5 specialty medication, meaning higher copays and prior authorization requirements apply.

Deductible Considerations

Most Humana Medicare Advantage plans apply the annual deductible to specialty medications. For 2024, this can range from $0 to $590 depending on your specific plan. Contact Humana member services at the number on your insurance card to confirm your deductible status.

Clinical Criteria for Approval

Primary Requirements

Diagnosis Confirmation: WHO Group I PAH must be confirmed by right heart catheterization showing:

  • Mean pulmonary arterial pressure >20 mmHg
  • Pulmonary arterial wedge pressure ≤15 mmHg
  • Pulmonary vascular resistance >2 Wood units

Step Therapy: Documentation of inadequate response or intolerance to at least two other PAH drug classes, with each therapy tried for minimum 60 days. Acceptable prior therapies include:

  • Endothelin receptor antagonists (ambrisentan, bosentan)
  • Phosphodiesterase-5 inhibitors (sildenafil, tadalafil)
  • Other prostacyclin pathway drugs

Specialist Prescription: Only pulmonologists or cardiologists can prescribe Uptravi for Humana coverage approval.

Supporting Clinical Data

Document current WHO functional class (II, III, or IV) and include 6-minute walk test results when available. Recent echocardiogram and any additional imaging studies strengthen the clinical picture.

Documentation Requirements

Medical Necessity Letter Components

Your specialist must submit a comprehensive letter including:

Patient Summary:

  • Complete PAH diagnosis with hemodynamic data
  • Current symptoms and functional limitations
  • Risk of disease progression without treatment

Prior Therapy History:

  • Specific medications tried with dates and doses
  • Reasons for discontinuation or inadequate response
  • Any contraindications to alternative treatments

Clinical Rationale:

  • Why Uptravi is medically necessary for this patient
  • Expected clinical benefits and monitoring plan
  • Reference to current PAH treatment guidelines

Required Attachments

Gather these documents before submission:

  • Right heart catheterization report
  • Echocardiogram results
  • 6-minute walk test (if performed)
  • Complete medication history
  • Recent clinic notes documenting functional status
Clinician Corner: The medical necessity letter should explicitly address CYP2C8 drug interactions, particularly confirming the patient is not taking gemfibrozil, which is contraindicated with selexipag.

Submission Process

Prior Authorization Form

Submit Humana's prior authorization request through their provider portal or by fax. The form requires:

  • Patient demographics and plan information
  • Prescriber details and DEA number
  • Complete clinical justification
  • All supporting documentation attached

Timeline Expectations

  • Standard review: Up to 30 calendar days
  • Expedited review: 72 hours (available when delay would jeopardize health)

Request expedited review if the patient has declining functional status or risk of hospitalization.

Common Denial Reasons & Solutions

Denial Reason Solution Key Documents
Insufficient step therapy Document all prior PAH medications with dates, doses, and outcomes Complete medication history with prescriber notes
Missing hemodynamic data Submit right heart catheterization results Official cardiology report with specific measurements
Wrong prescriber type Have pulmonologist or cardiologist resubmit Specialist prescription and medical necessity letter
Drug interaction concerns Address CYP2C8 inhibitors in clinical notes Current medication list with interaction screening
Incomplete medical necessity Strengthen clinical rationale with guidelines Detailed letter citing current PAH treatment standards

Appeals Process for Washington Residents

Internal Appeals (First Level)

If Humana denies coverage, you have 65 days from the denial notice to file an internal appeal. Include:

  • Written appeal request with specific reasons
  • Additional clinical documentation
  • Updated medical necessity letter addressing denial reasons

Timeline: Humana must respond within 7 days for standard appeals, 72 hours for expedited appeals.

Washington State External Review

After exhausting internal appeals, Washington residents can request an Independent Review Organization (IRO) external review within 60 days of the final internal denial.

How to Request:

  1. Contact your insurer to request external review
  2. Submit request to Washington State Office of Insurance Commissioner
  3. Provide all relevant medical records and documentation

Timeline:

  • Standard review: 20 days for fully-insured plans, 45 days for self-insured plans
  • Expedited review: 72 hours for urgent cases

Outcome: IRO decisions are binding on Humana. If approved, they must provide coverage.

From Our Advocates: We've seen PAH patients in Washington successfully overturn Humana denials through the IRO process when they submitted complete hemodynamic data and documented step therapy failures. The key is thorough documentation that clearly establishes medical necessity according to current guidelines.

Cost Considerations

Medicare Limitations

Medicare beneficiaries are not eligible for the Janssen withMe Program copay assistance. However, other options may help:

Patient Assistance Programs:

  • Pulmonary Hypertension Association maintains lists of financial assistance programs
  • Check eligibility for pharmaceutical manufacturer patient assistance

State Resources: Washington residents with limited income may qualify for additional state programs. Contact the Washington State Health Insurance Pool for guidance.

When to Escalate

Washington Insurance Commissioner

If you encounter problems with Humana's appeals process, contact the Washington State Office of the Insurance Commissioner:

Phone: 1-800-562-6900
Website: insurance.wa.gov

The OIC can help with:

  • Appeal process guidance
  • Complaint filing for procedural violations
  • Consumer advocacy services

Federal Resources

For Medicare-related issues, contact:

  • Medicare: 1-800-MEDICARE (1-800-633-4227)
  • SHIP (State Health Insurance Assistance Program): Free local counseling

Quick Reference Checklist

Before You Start

  • Active Humana Medicare Advantage coverage confirmed
  • Right heart catheterization results available
  • Documentation of at least two failed PAH therapies
  • Pulmonologist or cardiologist willing to prescribe
  • Current functional class assessment completed

For Prior Authorization

  • Complete Humana PA form submitted
  • Medical necessity letter addresses all clinical criteria
  • All supporting documents attached
  • Drug interaction screening documented
  • Submission confirmation received

If Denied

  • Internal appeal filed within 65 days
  • Additional clinical evidence submitted
  • External IRO review requested if internal appeal fails
  • All deadlines tracked and documented

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes for medications like Uptravi.

For comprehensive support with your Uptravi coverage challenge, Counterforce Health can help identify specific denial reasons and draft point-by-point appeals aligned to Humana's own coverage policies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual medical circumstances and plan policies. Always consult with your healthcare provider about treatment options and contact your insurance plan directly for coverage questions. For personalized assistance with appeals, consider consulting with qualified healthcare advocates or legal professionals familiar with Washington state insurance law.

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