By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by UnitedHealthcare in New Jersey: Prior Authorization, Appeals, and Coding Requirements

Answer Box: Quick Path to Approval

To get Uptravi (selexipag) covered by UnitedHealthcare in New Jersey: Submit prior authorization through the UHC Provider Portal with documented WHO Group 1 PAH diagnosis (ICD-10: I27.0 or I27.21), hemodynamic data showing mean PAP >20 mmHg, and evidence of failure/intolerance to two prior PAH therapies. If denied, you have 180 days to file internal appeals, then external review through New Jersey's IHCAP program. Start today: Gather your right heart catheterization results, 6-minute walk test data, and prior therapy records. Call UHC at 888-397-8129 or submit via the provider portal at UHCprovider.com.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for PAH Documentation
  3. Product Coding: HCPCS, J-Codes, and NDCs
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. UnitedHealthcare Verification Resources
  7. Pre-Submission Audit Checklist
  8. Appeals Process in New Jersey
  9. Cost-Saving Options and Support
  10. FAQ: Common Questions

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding how UnitedHealthcare processes Uptravi claims depends on the formulation you're prescribing. This distinction affects everything from prior authorization requirements to billing codes.

Oral Uptravi (Tablets) typically falls under the pharmacy benefit:

  • Dispensed through retail or specialty pharmacies
  • Requires prior authorization through OptumRx
  • Billed using NDC numbers (not J-codes)
  • Subject to step therapy and quantity limits

IV Uptravi (Injection) goes through the medical benefit:

  • Physician-administered in clinical settings
  • Billed using J3490 (unclassified drug code)
  • Requires buy-and-bill documentation
  • NDC: 66215-0718-01 for 1800 mcg single-dose vials
Note: UnitedHealthcare is phasing out some prior authorizations for chronic disease drugs, including certain lung disease medications like Uptravi. However, initial PA requirements still apply as of 2026.

ICD-10 Mapping for PAH Documentation

Accurate ICD-10 coding is crucial for Uptravi approval. UnitedHealthcare requires specific documentation to confirm WHO Group 1 pulmonary arterial hypertension.

Primary Codes for PAH

ICD-10 Code Description When to Use
I27.0 Primary pulmonary hypertension Idiopathic PAH, heritable PAH
I27.21 Secondary pulmonary arterial hypertension Drug-induced, connective tissue disease, HIV-associated, congenital heart disease

Documentation Requirements

Your clinical notes must include:

  • WHO Functional Class (I-IV) with objective measures
  • Hemodynamic data: Mean PAP >20 mmHg, PAWP ≤15 mmHg, PVR ≥3 Wood units
  • 6-minute walk test results (recommended but not mandatory)
  • Echocardiography findings supporting PAH diagnosis
Tip: Document functional class explicitly in progress notes. UnitedHealthcare reviewers look for phrases like "WHO FC III" or "NYHA Class II equivalent" with supporting objective data.

Product Coding: HCPCS, J-Codes, and NDCs

Oral Uptravi NDC Numbers

Strength NDC (11-digit) Package Size
200 mcg 66215-602-06 60 tablets
400 mcg 66215-604-06 60 tablets
600 mcg 66215-606-06 60 tablets
800 mcg 66215-608-06 60 tablets
1000 mcg 66215-610-06 60 tablets
Titration Pack 66215-628-20 140 tablets (mixed strengths)

IV Uptravi Medical Billing

For the IV formulation used when patients cannot tolerate oral therapy:

  • HCPCS Code: J3490 (Unclassified drugs)
  • NDC: 66215-0718-01 (1800 mcg single-dose vial)
  • Units: Report 1 mcg per unit (1800 units per vial)
  • Modifier: Add "UD" for 340B providers

Billing Units Calculation

When billing IV Uptravi with J3490:

  • Each vial contains 1800 mcg
  • Bill as 1800 units (1 mcg = 1 unit)
  • Include 11-digit NDC on claim line
  • Document dose equivalency if transitioning from oral

Clean Prior Authorization Request Anatomy

A successful UnitedHealthcare PA request for Uptravi includes these essential elements:

Required Clinical Documentation

1. Specialist Prescription

  • Prescribed by cardiologist, pulmonologist, or rheumatologist
  • Include provider NPI and specialty credentials

2. PAH Diagnosis Confirmation

  • Right heart catheterization results
  • Mean pulmonary artery pressure >20 mmHg
  • Pulmonary capillary wedge pressure ≤15 mmHg
  • Pulmonary vascular resistance ≥3 Wood units

3. Prior Therapy Documentation

  • At least two failed PAH therapies (≥60 days each)
  • Common combinations: PDE-5 inhibitors + endothelin receptor antagonists
  • Document specific reasons for failure (lack of efficacy, intolerance, contraindications)

4. Functional Status Assessment

  • Current WHO/NYHA functional class (II-IV)
  • 6-minute walk test results if available
  • Objective measures of activity limitation

Submission Process

Submit through the UHC Provider Portal under "Prior Authorization and Notification" or call 888-397-8129. Include all supporting documentation in a single submission to avoid delays.

From our advocates: We've seen the fastest approvals when providers submit a comprehensive packet upfront rather than responding to multiple requests for additional information. Include hemodynamic data, prior therapy records, and functional assessments in your initial submission.

Frequent Coding and Billing Pitfalls

Common Mistakes to Avoid

1. Unit Conversion Errors

  • IV Uptravi: Always use 1 mcg = 1 unit
  • Don't confuse vial size (1800 mcg) with billing units

2. Mismatched ICD-10 Codes

  • Avoid I27.2 or I27.20 for WHO Group 1 PAH
  • Use I27.21 specifically for secondary Group 1 conditions

3. Missing Prior Authorization

  • Both oral and IV formulations require PA
  • Don't assume specialty pharmacy will handle PA automatically

4. Incomplete Step Therapy Documentation

  • Must show adequate trials of two prior therapies
  • Include specific dates, doses, and reasons for discontinuation

5. Wrong Benefit Category

  • Oral tablets: Pharmacy benefit (NDC billing)
  • IV injection: Medical benefit (J-code billing)

UnitedHealthcare Verification Resources

Before submitting your PA request, verify current requirements using these UHC resources:

Provider Tools

  • UHC Provider Portal: Real-time PA status and requirements
  • PreCheck Tool: Automated approval for qualifying drugs (<30 seconds)
  • Provider Services: 888-397-8129 for PA questions

Policy Documents

Formulary Check

Verify Uptravi's formulary status and tier placement through the UHC provider portal or by calling the member services number on the patient's insurance card.

Pre-Submission Audit Checklist

Use this checklist before submitting your Uptravi PA request:

Clinical Documentation:

  • WHO Group 1 PAH diagnosis confirmed by right heart catheterization
  • ICD-10 code (I27.0 or I27.21) matches clinical scenario
  • Specialist prescription with appropriate credentials
  • Current functional class documented with objective measures

Prior Therapy Requirements:

  • Two prior PAH therapies documented (≥60 days each)
  • Specific reasons for failure/intolerance recorded
  • Contraindications to alternatives addressed

Technical Requirements:

  • Correct NDC or J-code for formulation
  • Proper billing units calculated
  • All required modifiers included
  • Supporting labs and imaging attached

Administrative Details:

  • Patient insurance verified and active
  • Provider enrolled in UHC network
  • PA submitted through correct channel (portal vs. phone)
  • All required forms completed

Appeals Process in New Jersey

If UnitedHealthcare denies your Uptravi PA request, New Jersey residents have robust appeal rights through the state's regulated process.

Internal Appeals (UHC)

Stage 1: Informal Review

  • File within 180 days of denial receipt
  • Contact UHC Community Plan NJ at (888) 362-3368
  • Timeline: 72 hours (urgent) or 10 days (standard)

Stage 2: Group Plans

  • File within 180 days of Stage 1 denial
  • Independent panel review by same specialty
  • Timeline: 72 hours (urgent) or 20 business days

External Review: New Jersey IHCAP

After completing internal appeals, you can request external review through New Jersey's Independent Health Care Appeal Program.

Key Details:

  • Deadline: 180 days from final internal denial
  • Cost: Free to patients (insurers pay all costs)
  • Process: Independent physician reviewers in relevant specialty
  • Timeline: 5 business days for acceptance, 45 days for decision
  • Contact: Maximus Federal Services at (888) 866-6205 or [email protected]

Required Documents:

  • All denial notices from UHC
  • Complete medical records
  • Additional clinical evidence supporting Uptravi's medical necessity
  • Provider's detailed medical necessity letter
Note: New Jersey's external review has binding authority over insurers. If the independent reviewers determine Uptravi is medically necessary, UnitedHealthcare must provide coverage.

For questions about the IHCAP process, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

Cost-Saving Options and Support

Uptravi's high cost (typically $9,000-$25,000 per month) makes financial assistance crucial for many patients.

Manufacturer Support

  • Janssen CarePath: Patient assistance programs and copay cards
  • Eligibility: Income-based for uninsured/underinsured patients
  • Contact: Visit Janssen's patient support website or call their patient services line

Foundation Grants

  • Patient Access Network Foundation: PAH-specific grants
  • HealthWell Foundation: Pulmonary arterial hypertension fund
  • Good Days: Chronic disease assistance

State Programs

New Jersey residents may qualify for additional assistance through state pharmaceutical programs. Contact NJ FamilyCare or the State Health Insurance Assistance Program (SHIP) for guidance.

When working with Counterforce Health, patients and providers can access streamlined appeals processes that turn insurance denials into targeted, evidence-backed appeals. The platform helps identify denial reasons and drafts point-by-point rebuttals aligned to UnitedHealthcare's specific requirements, potentially reducing the time and complexity of the appeals process.

FAQ: Common Questions

How long does UnitedHealthcare PA take for Uptravi in New Jersey? Standard PA requests typically receive decisions within 10-14 days. Urgent requests (when delay could cause serious harm) are processed within 72 hours.

What if Uptravi is non-formulary on my UHC plan? You can request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate or ineffective.

Can I request an expedited appeal if UHC denies Uptravi? Yes, if your condition is urgent and delay could cause serious harm. Contact UHC immediately to request expedited review (72-hour timeline).

Does step therapy apply if I failed PAH drugs outside New Jersey? Yes, UnitedHealthcare accepts prior therapy documentation from any provider, regardless of location, as long as it's properly documented.

What happens if I start Uptravi before PA approval? You'll be responsible for the full cost initially. If PA is later approved, UHC may provide retroactive coverage depending on your specific plan terms.

Can my doctor request a peer-to-peer review? Yes, UHC allows peer-to-peer discussions between your prescribing physician and their medical director. This can be requested through the provider portal or by calling provider services.

How do I know if my appeal was successful? UHC will send written notification of appeal decisions. You can also check status through the provider portal or by calling member services.

What if UHC requires quantity limits for Uptravi? Quantity limit exceptions can be requested by demonstrating medical necessity for the prescribed quantity, typically through documentation of dosing requirements and titration needs.

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider and insurance plan for the most current coverage policies and requirements. Insurance policies and coverage criteria can change frequently.

Sources & Further Reading

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes to identify denial reasons and draft comprehensive rebuttals aligned to each payer's specific requirements.

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