By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by UnitedHealthcare in Ohio: Complete Guide with Forms, Appeals & Contact Info

Answer Box: Getting Uptravi Covered by UnitedHealthcare in Ohio

UnitedHealthcare requires prior authorization for Uptravi (selexipag) in Ohio through OptumRx. The fastest path to approval: (1) Submit PA request via the UnitedHealthcare Provider Portal with complete PAH documentation, (2) Include WHO Group I PAH diagnosis, functional class, and prior therapy history, (3) If denied, file internal appeal within 180 days, then external review through Ohio Department of Insurance if needed. Start today: Call UnitedHealthcare at 1-800-711-4555 or use the provider portal to initiate prior authorization.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Online Access
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Network
  6. Support Lines & Who to Call
  7. Ohio Appeals & External Review Process
  8. Common Denial Reasons & How to Fix Them
  9. Costs & Patient Assistance
  10. FAQ: UnitedHealthcare Uptravi Coverage in Ohio

Verify Your Plan & Find the Right Forms

Before starting your Uptravi (selexipag) prior authorization, confirm your specific UnitedHealthcare plan type. Ohio residents may have:

  • Commercial/Marketplace plans (individual or employer-sponsored)
  • Medicare Advantage plans
  • Medicaid/Community Plan coverage

Each plan type has slightly different forms and submission requirements. Check your insurance card for plan details or log into the UnitedHealthcare member portal to verify coverage.

Tip: UnitedHealthcare's 2024 Ohio formularies show Uptravi typically requires prior authorization across all plan types, often placed on higher formulary tiers.

Prior Authorization Forms & Requirements

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Auth Required Yes, mandatory for all UHC plans OptumRx PA Portal
Formulary Tier Specialty tier (varies by plan) Plan-specific PDL documents
Step Therapy May require trying other PAH drugs first UHC medical policy
Quantity Limits Dosing must align with FDA labeling Provider portal submission
Diagnosis Requirement WHO Group I PAH with documentation Right heart catheterization results

Required Clinical Documentation

Your prescriber must provide:

  1. Confirmed PAH diagnosis with WHO Group I classification
  2. Functional class assessment (WHO Class II-IV symptoms)
  3. Right heart catheterization results showing elevated pulmonary pressures
  4. Prior therapy history including failures, intolerances, or contraindications
  5. Current treatment plan and monitoring approach
  6. Dosing rationale aligned with FDA-approved labeling

Submission Portals & Online Access

Primary Submission Methods

For Providers:

Portal Registration:

  • Obtain a One Healthcare ID for secure access
  • Upload clinical documents directly during PA workflow
  • Track authorization status in real-time
Important for Ohio Medicaid: As of June 2025, all appeals and reconsiderations must be submitted electronically through the Provider Portal—fax and mail submissions are no longer accepted.

What to Upload

When submitting through the portal, include:

  • Complete medical records supporting PAH diagnosis
  • Echocardiogram and right heart catheterization reports
  • Prior medication trial documentation
  • Current symptom assessment and functional status
  • Laboratory results (BNP, troponin if relevant)

Fax Numbers & Mailing Addresses

Current Contact Information

Prior Authorization Submissions:

Appeals Process:

  • Electronic submission required for Ohio Medicaid as of June 2025
  • Commercial plans: Use Provider Portal for fastest processing
  • Provider Web Support: 866-842-3278, option 1 (Monday-Friday, 7 AM-9 PM CT)
Note: UnitedHealthcare has transitioned most Ohio submissions to electronic-only processes. Always verify current submission methods through the provider portal.

Specialty Pharmacy Network

Uptravi must be dispensed through UnitedHealthcare's approved specialty pharmacy network in Ohio.

Getting Started with Specialty Pharmacy

  1. After PA approval, your prescription will be transferred to an in-network specialty pharmacy
  2. Patient enrollment includes medication counseling and delivery coordination
  3. Prescription transfers between specialty pharmacies require network verification
  4. Contact specialty pharmacy directly for refills and delivery scheduling

Transfer Process

If switching specialty pharmacies:

  • Verify the new pharmacy is in UnitedHealthcare's network
  • Patient, prescriber, or current pharmacy can initiate transfer
  • New pharmacy coordinates insurance verification and ongoing PA requirements

Support Lines & Who to Call

Key Phone Numbers

For Providers:

  • Prior Authorization: 1-800-711-4555 (OptumRx)
  • Provider Services: 800-600-9007 (Ohio-specific)
  • Portal Support: 866-842-3278, option 1

For Patients:

  • Member Services: Number on your insurance card
  • Specialty Pharmacy: Provided after PA approval

What to Ask When You Call

For PA Status:

  • "What's the status of prior authorization request for [patient name]?"
  • "What additional documentation is needed?"
  • "What's the expected decision timeline?"

For Denials:

  • "What was the specific reason for denial?"
  • "What evidence would support approval?"
  • "How do I request a peer-to-peer review?"

Ohio Appeals & External Review Process

Internal Appeals with UnitedHealthcare

If your Uptravi prior authorization is denied:

  1. File internal appeal within 180 days of denial notice
  2. Submit through Provider Portal (required for Medicaid; recommended for all plans)
  3. Include additional clinical evidence addressing denial reasons
  4. Expedited appeals available if delay could harm patient (72-hour review)

Ohio External Review

After exhausting internal appeals, Ohio residents can request external review:

Ohio Department of Insurance External Review:

  • Consumer Hotline: 1-800-686-1526
  • Timeline: Submit within 180 days of final UnitedHealthcare denial
  • Process: Independent Review Organization (IRO) conducts medical review
  • Cost: Free to consumers
  • Decision: Binding on UnitedHealthcare if overturned

How to Request:

  1. Call ODI at 1-800-686-1526 for guidance
  2. Submit written external review request
  3. Include all denial letters and supporting documentation
  4. ODI assigns case to independent medical experts

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Insufficient PAH documentation Provide right heart catheterization results, WHO classification
Step therapy not met Document failures/contraindications to required first-line therapies
Lack of specialist involvement Obtain prescription from pulmonologist or cardiologist
Dosing concerns Justify dose with FDA labeling or clinical guidelines
Missing functional assessment Include 6-minute walk test, WHO functional class documentation

Clinician Corner: Medical Necessity Letter

Your medical necessity letter should include:

  • Problem statement: Confirmed WHO Group I PAH with specific hemodynamic values
  • Prior treatments: Document trials of ERAs, PDE5 inhibitors, or other prostacyclin analogs
  • Clinical rationale: Why selexipag is appropriate for this patient's condition
  • Guideline support: Reference current PAH treatment guidelines
  • Monitoring plan: How you'll assess response and manage side effects

Costs & Patient Assistance

Financial Support Options

Manufacturer Support:

Ohio Resources:

  • Ohio Department of Medicaid: Coverage for eligible residents
  • 340B programs: Available at qualifying healthcare facilities
  • Patient advocacy organizations: Pulmonary Hypertension Association offers support resources
From our advocates: We've seen cases where patients initially faced $15,000+ monthly costs, but combining manufacturer assistance with successful appeals reduced out-of-pocket expenses to under $100 per month. The key is applying for all available programs while pursuing coverage approval simultaneously.

FAQ: UnitedHealthcare Uptravi Coverage in Ohio

How long does UnitedHealthcare prior authorization take in Ohio? Standard PA decisions are typically made within 72 hours to 14 days. Expedited reviews for urgent cases are completed within 72 hours.

What if Uptravi is non-formulary on my plan? Non-formulary drugs can still be covered through the exception process. Submit a formulary exception request with strong medical necessity documentation.

Can I request an expedited appeal? Yes, if delaying Uptravi could seriously jeopardize your health. Document the urgent medical need and submit through the Provider Portal.

Does step therapy apply if I've failed therapies outside Ohio? Yes, prior therapy failures from any location count toward step therapy requirements. Provide complete documentation of previous treatments.

What happens if my internal appeal is denied? You can request external review through the Ohio Department of Insurance within 180 days. This independent review is free and binding on UnitedHealthcare.

How do I transfer my prescription between specialty pharmacies? Contact your current specialty pharmacy or the new pharmacy to initiate the transfer. Ensure the receiving pharmacy is in UnitedHealthcare's network.

Getting your Uptravi covered shouldn't be a battle you fight alone. Counterforce Health helps patients and providers turn insurance denials into successful appeals by creating evidence-backed, payer-specific appeal letters. Our platform analyzes denial letters, identifies the specific coverage criteria, and drafts targeted rebuttals using the right clinical evidence and procedural requirements for each insurer and state.

If you're facing a UnitedHealthcare denial for Uptravi in Ohio, Counterforce Health can help you build a stronger case with the documentation and arguments most likely to succeed in your specific situation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies and requirements may change. Always verify current information with UnitedHealthcare and consult your healthcare provider for medical decisions. For official appeals guidance in Ohio, contact the Ohio Department of Insurance at 1-800-686-1526.

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