By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by UnitedHealthcare in Texas: Complete Guide to Prior Authorization, Appeals, and Approval

Answer Box: Getting Started

To get Uptravi (selexipag) covered by UnitedHealthcare in Texas: Your doctor submits a prior authorization through the UnitedHealthcare Provider Portal or by calling 888-397-8129. You'll need documented WHO Group I PAH diagnosis, functional class II-IV status, and evidence of step therapy compliance or contraindications to preferred agents. If denied, Texas law guarantees internal appeals (180 days) and external review through an Independent Review Organization. Start today: Verify your plan's formulary status and gather your PAH diagnosis documentation, prior therapy records, and current functional assessment.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Process
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Enrollment
  6. Support Lines and Case Management
  7. Appeals Process and Texas IRO
  8. Common Denial Reasons and Solutions
  9. Costs and Patient Assistance
  10. FAQ

Start Here: Verify Your Plan and Coverage

Before starting the prior authorization process, confirm your UnitedHealthcare plan details and Uptravi's coverage status.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, for all plans UnitedHealthcare Provider Portal UHC PA Requirements
Step Therapy Required unless contraindicated Plan formulary documents Step Therapy Updates
Specialty Pharmacy Required for dispensing Network directory Specialty Pharmacy List
Appeals Deadline 180 days from denial Denial letter Texas Insurance Code

First Steps:

  1. Call the member services number on your insurance card to confirm Uptravi coverage
  2. Ask specifically about your plan's formulary tier and step therapy requirements
  3. Request a copy of your plan's specialty drug prior authorization form

Prior Authorization Forms and Requirements

UnitedHealthcare requires comprehensive clinical documentation for Uptravi prior authorization requests.

Required Clinical Documentation

Essential Information:

  • Member demographics and insurance details
  • Prescriber NPI and specialty credentials
  • Diagnosis: WHO Group I PAH confirmed by right heart catheterization
  • Functional Status: WHO functional class II, III, or IV documentation
  • Exclusion Documentation: Rule out Groups 2-5 pulmonary hypertension
  • Prior Therapy History: Detailed records of previous PAH treatments, responses, and discontinuation reasons

Step Therapy Requirements

UnitedHealthcare typically requires patients to try preferred PAH therapies first, including:

  • PDE5 Inhibitors: Sildenafil, tadalafil
  • Endothelin Receptor Antagonists: Ambrisentan, bosentan
  • Prostacyclin Pathway Agents: Treprostinil, epoprostenol

Step Therapy Exceptions:

  • Documented contraindications to preferred agents
  • Severe adverse effects from required medications
  • Clinical rationale why preferred agents aren't suitable
Clinician Corner: Your medical necessity letter should include specific PAH hemodynamic data (pulmonary artery pressure, pulmonary vascular resistance), 6-minute walk test results, and detailed documentation of previous therapy failures or contraindications. Reference current AHA/ACC Pulmonary Hypertension Guidelines to strengthen your clinical rationale.

Submission Portals and Upload Process

Primary Submission Method: Provider Portal

UnitedHealthcare Provider Portal Steps:

  1. Visit UHCprovider.com
  2. Sign in with your One Healthcare ID (register at UHCprovider.com/access if needed)
  3. Select "Prior Authorization and Notification" from your dashboard
  4. Complete the PA request form with all required clinical documentation
  5. Upload supporting documents (chart notes, lab results, imaging)

Processing Timeline: Most complete requests are processed within 4 business days. Expedited review (≤72 hours) is available for urgent cases.

Alternative Submission Methods

  • Phone: 888-397-8129 (24/7 availability)
  • Fax: 877-940-1972 (include cover sheet with member information)
  • 24/7 Chat: Available through the Contact Us page on UHCprovider.com

Fax Numbers and Mailing Addresses

Key Contact Information

Prior Authorization Submissions:

  • Fax: 877-940-1972
  • Phone: 888-397-8129

Member Services:

  • General: 1-866-347-9507 (Monday-Friday, 7 AM-6 PM CT)
  • STAR Kids: 1-877-597-7799

Provider Relations:

  • Community Plan: 1-866-858-3546
Tip: When faxing, include a detailed cover sheet with member name, ID number, prescriber NPI, and "URGENT - PAH Medication Prior Authorization" if time-sensitive.

Specialty Pharmacy Enrollment

Uptravi must be dispensed through a UnitedHealthcare network specialty pharmacy.

Enrollment Process

Step-by-Step Specialty Pharmacy Setup:

  1. Verify Network Pharmacy: Use the pharmacy locator to find in-network specialty pharmacies serving Texas
  2. Initiate Enrollment: Contact your chosen specialty pharmacy directly
  3. Provide Documentation: Share insurance information, prescription, and PA approval
  4. Complete Clinical Assessment: Specialty pharmacists will conduct medication counseling
  5. Arrange Delivery: Set up home delivery or local pickup options

Optum Specialty Pharmacy is UnitedHealthcare's primary specialty partner, offering:

  • Statewide Texas coverage via mail delivery
  • Dedicated patient care teams
  • Clinical support and education
  • Coordination with your healthcare team

Prescription Transfer Process

If transferring from another pharmacy:

  1. Contact your new in-network specialty pharmacy
  2. Provide current prescription details and remaining refills
  3. The specialty pharmacy will coordinate the transfer
  4. Ensure no therapy gaps by initiating transfer before running out

Support Lines and Case Management

When to Call Each Number

Member Services (1-866-347-9507):

  • Check prior authorization status
  • Verify coverage and benefits
  • Request denial letter copies
  • Initiate internal appeals

Provider Relations (1-866-858-3546):

  • Clinical questions about PA requirements
  • Step therapy exception requests
  • Peer-to-peer review scheduling
  • Technical portal issues

What to Ask:

  • "What's the current status of PA request [reference number]?"
  • "What specific clinical documentation is missing?"
  • "Can we schedule a peer-to-peer review with the medical director?"
  • "What's the exact step therapy requirement for this member's plan?"

Appeals Process and Texas IRO

Texas provides strong appeal rights for insurance denials, including access to Independent Review Organizations.

Appeals Timeline

Level Deadline Decision Time How to Submit
Internal Appeal 180 days from denial 30 days (pre-service) Provider Portal or member services
External Review (IRO) 4 months from final denial 20 days (standard), 5 days (urgent) Texas Department of Insurance

Internal Appeals Process

  1. Gather Documentation: Denial letter, medical records, additional clinical evidence
  2. Submit Appeal: Through provider portal or by calling member services
  3. Include New Evidence: Any additional documentation supporting medical necessity
  4. Request Peer-to-Peer: Ask for a clinical review with UnitedHealthcare's medical director

External Review (IRO)

If your internal appeal is denied, Texas law provides access to an Independent Review Organization.

IRO Process:

  1. Request Form: UnitedHealthcare must provide an IRO request form with their final denial
  2. Submit to TDI: Send completed form to the Texas Department of Insurance
  3. Independent Review: External medical experts review your case
  4. Binding Decision: If the IRO approves, UnitedHealthcare must cover the medication

Texas Department of Insurance IRO Contact:

Note: The IRO decision is binding on UnitedHealthcare. If they rule in your favor, your insurance must provide coverage for Uptravi.

Common Denial Reasons and Solutions

Typical Denial Reasons and How to Address Them

Denial Reason Solution Required Documentation
Lack of WHO Group I PAH diagnosis Submit right heart catheterization results Hemodynamic data, imaging, specialist notes
Missing functional class documentation Provide current assessment 6-minute walk test, WHO functional class evaluation
Step therapy not completed Document contraindications or failures Prior therapy records, adverse event documentation
Insufficient clinical justification Strengthen medical necessity letter Guidelines citations, treatment goals, monitoring plan
Missing specialist consultation Obtain cardiology/pulmonology consult Specialist evaluation and recommendation

Strengthening Your Appeal

Key Elements for Success:

  • Specific Clinical Data: Include exact hemodynamic measurements and functional assessments
  • Guideline References: Cite current AHA/ACC or ESC/ERS pulmonary hypertension guidelines
  • Treatment History: Document specific medications tried, doses, duration, and reasons for discontinuation
  • Contraindication Documentation: Provide detailed medical reasons why preferred agents aren't suitable

Costs and Patient Assistance

Uptravi's retail cost ranges from $9,000-$25,000 monthly, making patient assistance crucial.

Financial Support Options

Janssen Patient Assistance:

  • CarePath Savings Program: Potential copay reduction for eligible patients
  • Patient Assistance Program: Free medication for qualifying uninsured/underinsured patients
  • Information: Visit Janssen CarePath or call 1-877-CAREPATH

Additional Resources:

  • Good Days: Chronic disease financial assistance
  • PAN Foundation: Pulmonary arterial hypertension fund
  • State Programs: Texas has limited specialty drug assistance programs
From Our Advocates: "We've seen patients successfully appeal Uptravi denials by working closely with their pulmonologist to document specific hemodynamic improvements needed and why other PAH therapies weren't suitable. The key is comprehensive clinical documentation and persistence through the appeals process. While outcomes vary, thorough preparation significantly improves approval chances."

FAQ

How long does UnitedHealthcare prior authorization take in Texas? Standard review takes up to 4 business days. Expedited review for urgent cases is completed within 72 hours.

What if Uptravi is non-formulary on my plan? Non-formulary medications can still be covered through prior authorization and medical necessity documentation. Focus on clinical justification and step therapy exceptions.

Can I request an expedited appeal? Yes, if delaying treatment would jeopardize your health. Both internal appeals and external IRO reviews can be expedited in Texas.

Does step therapy apply if I failed other PAH medications outside Texas? Yes, document all prior therapy attempts regardless of where they occurred. UnitedHealthcare accepts out-of-state medical records for step therapy requirements.

What happens if my appeal is denied? You can request an external review through the Texas Department of Insurance IRO process. This independent review is binding on UnitedHealthcare.

How do I find a UnitedHealthcare specialty pharmacy in Texas? Use the Optum pharmacy locator or call member services at 1-866-347-9507 for network specialty pharmacies.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes. Our platform analyzes denial letters and insurance policies to create targeted, evidence-backed appeals that turn denials into approvals. If you're facing challenges getting Uptravi covered, our tools can help identify the specific denial basis and draft point-by-point rebuttals aligned with UnitedHealthcare's requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider and insurance company for plan-specific requirements. For additional assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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