By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by UnitedHealthcare in New York: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Uptravi Covered by UnitedHealthcare in New York

Uptravi (selexipag) requires prior authorization from UnitedHealthcare for pulmonary arterial hypertension (PAH) patients in New York. Your fastest path to approval:

  1. Confirm WHO Group I PAH diagnosis with right heart catheterization results
  2. Document step therapy (failed PDE5 inhibitors or ERAs, unless contraindicated)
  3. Submit OptumRx PA form via provider portal with PAH specialist involvement

Start today: Gather your right heart cath results, prior therapy records, and contact your PAH specialist to initiate the OptumRx prior authorization. Standard review takes up to 15 business days; expedited review available for urgent cases within 72 hours.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You're Asked for More Information
  7. If Your Request Is Denied
  8. Appeals Process in New York
  9. Renewal and Re-authorization
  10. FAQ
  11. Quick Reference Checklist

What This Guide Covers

This guide helps New York patients with pulmonary arterial hypertension (PAH) navigate UnitedHealthcare's prior authorization process for Uptravi (selexipag)—a specialized oral medication that can cost $9,000-$25,000 monthly without insurance coverage.

Who this helps:

  • PAH patients whose doctors recommend Uptravi
  • Caregivers managing insurance approvals
  • Clinicians submitting prior authorizations
  • Anyone facing a UnitedHealthcare denial

Uptravi is an oral prostacyclin receptor agonist approved by the FDA to delay disease progression and reduce PAH-related hospitalizations. UnitedHealthcare requires strict documentation and specialist involvement for approval.

Before You Start: Verify Your Coverage

Check Your Plan Details

Confirm these basics before submitting:

Requirement How to Verify Where to Look
Plan type Commercial, Medicare Advantage, or Medicaid Member ID card
Formulary status Is Uptravi covered? What tier? UnitedHealthcare formulary lookup
Specialty pharmacy Must use OptumRx network Member services: 1-888-867-4621
Prior authorization Required for all PAH medications Provider portal or member handbook
Note: Uptravi must be dispensed through UnitedHealthcare's preferred specialty pharmacy network, primarily Optum Specialty Pharmacy. Retail pharmacies cannot fill this prescription.

Verify Network Status

Ensure your PAH specialist is in-network with UnitedHealthcare. Out-of-network specialists may require additional approvals and result in higher costs.

Gather What You Need

Essential Documentation Checklist:

Medical Records

  • Right heart catheterization results confirming WHO Group I PAH
  • Functional class assessment (WHO Class II, III, or IV symptoms)
  • Six-minute walk test results (if available)
  • Echocardiogram and other cardiac imaging
  • Complete medical history including onset and progression

Prior Therapy Documentation

  • PDE5 inhibitors (sildenafil, tadalafil): dosing, duration, outcomes
  • Endothelin receptor antagonists (ambrisentan, bosentan): trial details
  • Other PAH medications attempted
  • Reasons for discontinuation (ineffective, intolerance, contraindications)

Prescriber Information

  • PAH specialist credentials (pulmonologist, cardiologist, or rheumatologist)
  • Medical necessity letter with clinical rationale
  • Treatment plan including monitoring strategy

Insurance Documents

  • Current UnitedHealthcare member ID card
  • OptumRx prior authorization form (available via provider portal)
  • Previous denial letters (if resubmitting)

Submit the Prior Authorization Request

Step-by-Step Submission Process

1. Access the OptumRx PA Form

  • Log into the UnitedHealthcare Provider Portal
  • Navigate to "Prior Authorization" under pharmacy services
  • Download the current OptumRx Prior Authorization Request Form
  • Alternative: Fax requests to 1-844-403-1027 (verify current number)

2. Complete Required Sections

  • Patient demographics and correct Payer ID from member card
  • Diagnosis codes (ICD-10 for WHO Group I PAH)
  • Drug information (Uptravi NDC, strength, quantity)
  • Prescriber details and specialty credentials

3. Attach Supporting Documents

  • Right heart catheterization report
  • Medical necessity letter from PAH specialist
  • Prior therapy documentation
  • Current clinical notes

4. Submit Through Preferred Channels

  • Electronic submission via provider portal (fastest)
  • CoverMyMeds for streamlined ePA processing
  • Fax for urgent cases (include "URGENT" marking)
Tip: Electronic submissions through the provider portal typically process faster than fax submissions and provide real-time status tracking.

Follow-Up and Timelines

Expected Processing Times

Review Type Timeline When Available
Standard review Up to 15 business days Routine requests
Expedited review Within 72 hours Urgent medical need
Additional information 5-7 days after submission When documentation incomplete

Follow-Up Best Practices

Call OptumRx at 1-800-711-4555 if:

  • No response after 10 business days
  • Status shows "pending additional information"
  • Patient's condition is deteriorating

Sample Follow-Up Script: "I'm calling about a prior authorization for Uptravi for my patient [name], member ID [number]. The request was submitted on [date] and I need to check the status. Can you tell me if any additional information is needed?"

Document everything:

  • Reference numbers from each call
  • Representative names and callback numbers
  • Specific information requested
  • Deadlines provided

If You're Asked for More Information

Common Information Requests

Clinical Clarification:

  • More detailed functional assessment
  • Specific hemodynamic parameters
  • Treatment response measurements
  • Drug interaction screening

Prior Therapy Details:

  • Exact dosing and duration of previous medications
  • Specific adverse events or contraindications
  • Documentation of treatment failures
  • Timeline of disease progression

Medical Necessity Letter Essentials

Your PAH specialist should include:

  1. Patient's specific diagnosis and WHO Group classification
  2. Disease severity and functional limitations
  3. Previous treatments tried with specific outcomes
  4. Clinical rationale for Uptravi based on FDA labeling and guidelines
  5. Treatment goals and monitoring plan
  6. References to current PAH management guidelines
Clinician Corner: Reference the 2022 ESC/ERS Pulmonary Hypertension Guidelines and FDA prescribing information to strengthen medical necessity arguments.

If Your Request Is Denied

Common Denial Reasons & Solutions

Denial Reason How to Address
"Not WHO Group I PAH" Submit complete right heart catheterization with hemodynamics
"Step therapy not completed" Document prior PDE5i/ERA trials or provide contraindication rationale
"Functional class not severe enough" Include six-minute walk test, symptoms diary, quality of life measures
"Prescriber not qualified" Ensure PAH specialist involvement and credential verification

Internal Appeal Process

File within 180 days of denial:

  1. Gather denial letter and identify specific reasons
  2. Collect additional evidence addressing each denial point
  3. Submit appeal via UnitedHealthcare Provider Portal
  4. Request peer-to-peer review with UnitedHealthcare medical director
  5. Track appeal status and respond to requests promptly

Peer-to-Peer Review Tips:

  • Schedule when your PAH specialist is available
  • Prepare talking points addressing denial reasons
  • Reference specific policy language and clinical guidelines
  • Document the conversation outcome

Appeals Process in New York

New York patients have strong appeal rights through the New York State Department of Financial Services (DFS).

External Appeal Process

When to File:

  • After completing UnitedHealthcare's internal appeal
  • Within 4 months of final adverse determination
  • For denials based on medical necessity, experimental treatment, or network issues

How to File:

  1. Complete DFS External Appeal Application
  2. Submit supporting documents (denial letters, medical records, provider letters)
  3. Mail or fax to DFS (forms available at dfs.ny.gov)
  4. Request expedited review if treatment delay poses health risks

Timeline for External Appeals

Appeal Type Decision Timeline Requirements
Standard external appeal 30 days Complete application with supporting docs
Expedited appeal 72 hours Physician attestation of medical urgency
Emergency drug appeal 24 hours Life-threatening delay certification

DFS Contact Information:

New York Advantage: External appeal decisions are binding on UnitedHealthcare. If DFS overturns the denial, your insurer must approve and cover Uptravi.

Additional New York Resources

Community Health Advocates: 888-614-5400

  • Free assistance with insurance appeals
  • Help completing DFS forms
  • Advocacy throughout the process

Renewal and Re-authorization

Annual Renewal Requirements

Uptravi prior authorizations typically require renewal every 12 months. Calendar the renewal 60 days before expiration to avoid treatment interruption.

Renewal Documentation:

  • Updated clinical assessment showing continued benefit
  • Current functional status and any improvements
  • Ongoing treatment plan and monitoring results
  • Confirmation of continued medical necessity

What Speeds Renewal Approval

  • Objective improvements (six-minute walk distance, functional class)
  • Reduced hospitalizations or emergency visits
  • Stable or improved hemodynamics (if repeat catheterization performed)
  • Good medication tolerance with manageable side effects

FAQ

How long does UnitedHealthcare PA take in New York? Standard review takes up to 15 business days. Expedited review for urgent cases is completed within 72 hours. Electronic submissions via the provider portal typically process faster than fax submissions.

What if Uptravi is non-formulary on my plan? Non-formulary medications require additional documentation showing medical necessity and that formulary alternatives are inappropriate. Your PAH specialist must provide detailed rationale for why covered alternatives won't work.

Can I request an expedited appeal? Yes, if treatment delay poses serious health risks. Your physician must provide written attestation of medical urgency. Expedited appeals in New York are decided within 72 hours.

Does step therapy apply if I failed treatments outside New York? Previous treatment trials from other states are typically accepted if well-documented. Provide complete records including dosing, duration, and specific reasons for discontinuation.

What if my PAH specialist is out-of-network? Out-of-network specialists may still prescribe Uptravi, but you'll likely pay higher costs. Consider requesting a network exception if no in-network PAH specialists are available in your area.

How do I find UnitedHealthcare's specialty pharmacy network? Contact member services at 1-888-867-4621 or check your member portal. Optum Specialty Pharmacy is typically the preferred provider for Uptravi in New York.

Quick Reference Checklist

Before Submitting PA:

  • Verify Uptravi is on your formulary
  • Confirm OptumRx specialty pharmacy requirement
  • Ensure PAH specialist is in-network
  • Gather right heart catheterization results
  • Document all prior PAH therapy trials

PA Submission:

  • Complete OptumRx PA form via provider portal
  • Attach medical necessity letter from PAH specialist
  • Include prior therapy documentation
  • Submit electronically for fastest processing
  • Save confirmation and reference numbers

If Denied:

  • Review denial letter for specific reasons
  • Gather additional supporting evidence
  • File internal appeal within 180 days
  • Request peer-to-peer review
  • Consider New York DFS external appeal if needed

For Ongoing Coverage:

  • Calendar renewal 60 days before expiration
  • Document treatment benefits and improvements
  • Maintain regular PAH specialist follow-up
  • Keep all insurance communications

Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Uptravi. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals that speak directly to each payer's requirements. By combining clinical expertise with payer-specific workflows, we help patients, clinicians, and specialty pharmacies navigate complex prior authorization processes more effectively. Learn more at counterforcehealth.org.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not replace professional medical advice. Coverage decisions depend on individual circumstances, plan details, and clinical factors. Always consult your healthcare provider about treatment options and work with your insurance company for plan-specific requirements. For personalized assistance with insurance appeals and prior authorizations, consider consulting with specialists at Counterforce Health who focus specifically on coverage challenges for specialty medications.

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