By Counterforce Health Team in Uptravi (selexipag) —

How to Get Uptravi (Selexipag) Covered by UnitedHealthcare in Washington: Forms, Appeals & Contacts

Answer Box: Getting Uptravi Covered by UnitedHealthcare in Washington

UnitedHealthcare requires prior authorization for Uptravi (selexipag) in Washington. The fastest path to approval: 1) Verify your plan's formulary status and PA requirements through the UnitedHealthcare provider portal, 2) Submit complete clinical documentation including confirmed WHO Group I PAH diagnosis, prior therapy failures, and hemodynamic data, and 3) Use OptumRx's electronic PA system for expedited processing. If denied, Washington residents have strong appeal rights including external review through an Independent Review Organization (IRO) overseen by the state Insurance Commissioner.

Table of Contents

  1. Start Here: Verify Your Plan & Find Forms
  2. Required Forms & Documentation
  3. Submission Portals & Electronic Systems
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Enrollment
  6. Support Phone Numbers & Case Management
  7. Washington State Appeals & Consumer Help
  8. Coverage Requirements at a Glance
  9. Common Denial Reasons & Solutions
  10. Frequently Asked Questions

Start Here: Verify Your Plan & Find Forms

Before starting your Uptravi prior authorization, confirm your specific UnitedHealthcare plan details. Coverage varies between Commercial, Medicare Advantage, and Medicaid (Apple Health) plans in Washington.

Essential First Steps:

  1. Check your member ID card for the specific plan type and member services number
  2. Log into the UnitedHealthcare member portal to verify Uptravi's formulary status
  3. Confirm if OptumRx manages your prescription benefits (most UnitedHealthcare plans use OptumRx)
Tip: UnitedHealthcare's 2025 member ID cards display updated Payer IDs. Always verify you're using the correct plan identifier before submitting documentation.

Required Forms & Documentation

Prior Authorization Forms

UnitedHealthcare requires specific PA forms for Uptravi, available through:

  • UnitedHealthcare Provider Portal (most current versions)
  • OptumRx PA forms for prescription benefit coverage
  • Washington-specific Community Plan forms for Apple Health members

Required Clinical Documentation:

  • Confirmed WHO Group I pulmonary arterial hypertension diagnosis
  • Right heart catheterization results or specialist attestation
  • Functional class (NYHA/WHO Class II-IV) documentation
  • 6-minute walk test results
  • Prior PAH therapy trials and outcomes (failure/intolerance documentation)
  • Current hemodynamic parameters
  • Contraindications to alternative therapies

Medical Necessity Letter Checklist

Your prescriber's letter should include:

  • Patient demographics and diagnosis with ICD-10 codes
  • Clinical presentation and disease severity
  • Prior treatments tried (ERAs, PDE5 inhibitors, other prostacyclin analogs)
  • Rationale for Uptravi based on FDA labeling and clinical guidelines
  • Dosing plan and monitoring approach
  • Treatment goals and expected outcomes

Submission Portals & Electronic Systems

UnitedHealthcare Provider Portal

Access Requirements:

Submission Process:

  1. Log in with One Healthcare ID
  2. Select "Prior Authorization and Notification" tool
  3. Verify member's Payer ID matches plan type
  4. Upload required clinical documentation directly
  5. Track request status through portal dashboard

OptumRx Electronic Systems

UnitedHealthcare uses OptumRx PreCheck Prior Authorization for automated processing when all electronic medical record criteria are met, reducing approval times to seconds for qualifying requests.

Electronic Submission Options:

  • CoverMyMeds integration for streamlined processing
  • Direct EHR integration where available
  • Provider portal upload for manual submissions

Fax Numbers & Mailing Addresses

Important: Always verify current fax numbers and addresses through your member's specific plan documentation, as these can change frequently.

General UnitedHealthcare PA Fax:

  • Check the back of member ID card for plan-specific fax numbers
  • Include complete cover sheet with member ID, prescriber NPI, and urgency level

Mailing Address: Confirm current mailing address through the UnitedHealthcare provider portal or member services, as addresses vary by plan type and region.

Cover Sheet Best Practices:

  • Mark "URGENT" if clinically appropriate
  • Include member ID, date of birth, and prescriber information
  • List all attached documents
  • Provide callback number for questions

Specialty Pharmacy Enrollment

Uptravi requires dispensing through UnitedHealthcare's contracted specialty pharmacy network.

Approved Specialty Pharmacies

Key Network Partners:

  • Optum Specialty Pharmacy
  • Accredo Health Group
  • Orsini Pharmaceutical Services: 800-240-9572
  • Amber Specialty Pharmacy

Enrollment Process

  1. Prescriber submits prescription to approved specialty pharmacy
  2. Benefits verification and prior authorization coordination
  3. Patient enrollment including medication counseling and adherence support
  4. Direct-to-patient shipping or provider delivery as appropriate
  5. Ongoing clinical support with 24/7 pharmacist availability
Note: The specialty pharmacy will coordinate prior authorization submission and can expedite urgent requests directly with UnitedHealthcare.

Support Phone Numbers & Case Management

Member Services

  • Primary contact: Number on back of UnitedHealthcare member ID card
  • Available: 24/7 for urgent clinical questions
  • Services: PA status checks, appeal assistance, specialty pharmacy coordination

Provider Services

  • Access through: UnitedHealthcare provider portal or member card number
  • Specialty medication support: Direct connection to case management
  • Urgent authorizations: Mark requests as "urgent" for expedited processing

Specialty Pharmacy Clinical Support

  • Orsini Pharmaceutical Services: 800-240-9572, Fax: 847-427-7976
  • 24/7 clinical teams available for medication questions
  • Patient adherence support and safety monitoring

Washington State Appeals & Consumer Help

Washington residents have robust appeal rights when UnitedHealthcare denies Uptravi coverage.

Appeals Process Timeline

  1. Internal Appeal (required first step)
    • Submit within 180 days of denial
    • UnitedHealthcare has specific timeframes for response
    • Can request expedited review for urgent cases
  2. External Review (IRO)
    • Request after internal appeal denial
    • Independent Review Organization assigned by state
    • Timeline: 15-20 days for standard, 72 hours for urgent
    • Decision is binding on UnitedHealthcare

Washington State Resources

Office of the Insurance Commissioner (OIC):

  • Consumer Advocacy Hotline: 1-800-562-6900
  • Website: insurance.wa.gov
  • Services: Appeal guidance, complaint filing, IRO process assistance

External Review Database:

  • Search past IRO decisions at fortress.wa.gov/consumertoolkit/Search.aspx
  • Useful for understanding successful appeal strategies
Washington Advantage: The state's external review process has independent medical specialists who can override insurer denials based on medical necessity, even if the plan's initial criteria weren't met.

Coverage Requirements at a Glance

Requirement Details Where to Find
Prior Authorization Required for all plans UnitedHealthcare provider portal
Diagnosis WHO Group I PAH confirmed Clinical documentation
Functional Class NYHA/WHO Class II-IV 6-minute walk test, specialist notes
Prior Therapies Document failures/intolerances Medical records, pharmacy claims
Specialty Pharmacy Required dispensing Provider Vendor Assistance List
Appeals Deadline 180 days from denial Washington state law

Common Denial Reasons & Solutions

Denial Reason Solution
Incomplete PA documentation Submit complete clinical package with all required elements
Step therapy not met Document contraindications or failures of required first-line therapies
Non-formulary status Request formulary exception with medical necessity justification
Quantity limits exceeded Provide clinical rationale for prescribed dosing
"Not medically necessary" Submit peer-reviewed evidence and specialty guidelines supporting use

When facing denials, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific criteria.

Frequently Asked Questions

Q: How long does UnitedHealthcare PA take for Uptravi in Washington? A: Standard PA decisions typically take 15 business days. OptumRx's PreCheck system can provide instant approvals when all criteria are met electronically. Urgent requests receive expedited review within 72 hours.

Q: What if Uptravi is non-formulary on my plan? A: Request a formulary exception by demonstrating medical necessity and documenting why preferred alternatives are inappropriate or have failed.

Q: Can I request an expedited appeal in Washington? A: Yes, if delay could seriously jeopardize your health. Mark appeals as "urgent" and Washington's external review process provides 72-hour decisions for urgent cases.

Q: Does step therapy apply if I've tried PAH medications outside Washington? A: Yes, document all prior PAH therapies regardless of where they were tried. Include pharmacy records, physician notes, and outcomes documentation.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by UnitedHealthcare. External appeals in Washington are reviewed by independent medical specialists through state-certified IROs, and their decisions are binding on the insurer.

Q: Who can help if I'm having trouble with the appeals process? A: Contact the Washington Office of the Insurance Commissioner at 1-800-562-6900 for free consumer advocacy assistance throughout the appeals process.

For patients and families navigating complex prior authorization requirements, Counterforce Health provides specialized support in transforming insurance denials into successful appeals through targeted, evidence-based advocacy that aligns with each payer's specific policies and procedures.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For personalized assistance with appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.