By Counterforce Health Team in Uptravi (selexipag) —

Renewing Uptravi (Selexipag) Coverage with Cigna in Pennsylvania: Timeline, Documentation & Appeal Rights

Answer Box: Uptravi (Selexipag) Renewal Process

Renewal Timeline: Cigna approves Uptravi for 1-year periods. Start renewal 60-90 days before expiration to avoid gaps. Required Documentation: WHO Group I PAH confirmation, 6-minute walk test results, functional class assessment, and tolerability records. Submit Through: Cigna provider portal at covermymeds.com or precertification line on your insurance card. Pennsylvania Rights: If denied, you have 180 days for internal appeals, then 4 months for state external review with 50% overturn rate.

Table of Contents

  1. When to Start Your Renewal
  2. Required Documentation Checklist
  3. Submission Process and Timeline
  4. If Your Renewal Gets Denied
  5. Annual Plan Changes to Monitor
  6. Coverage Gap Bridge Options
  7. Pennsylvania External Review Process
  8. Personal Tracking Template

When to Start Your Renewal

Cigna typically approves Uptravi (selexipag) for one-year periods, with renewal approvals also granted for one-year terms. Here's when to begin the renewal process:

Start 60-90 Days Early if you have:

  • Previous authorization challenges or delays
  • Changes in your PAH specialist or clinic
  • Recent hospitalizations or disease progression
  • New insurance plan or formulary changes

Start 30-60 Days Early for routine renewals with:

  • Stable disease on current therapy
  • Established relationship with prescribing specialist
  • No recent insurance plan changes
Tip: Set a calendar reminder 90 days before your current authorization expires. Uptravi is a critical therapy for PAH, and treatment interruptions can lead to clinical deterioration.

Required Documentation Checklist

Your pulmonary hypertension specialist must provide comprehensive documentation demonstrating continued medical necessity:

Clinical Diagnosis Confirmation

  • Ongoing WHO Group I pulmonary arterial hypertension diagnosis
  • Current specialist oversight by cardiologist or pulmonologist
  • Recent hemodynamic assessment or echocardiographic data (if available)

Treatment Response Evidence

  • 6-minute walk test results showing maintained or improved functional capacity
  • WHO/NYHA functional class assessment (Class II-IV documentation)
  • Clinical notes documenting absence of disease progression
  • Right ventricular function assessment via echocardiography

Medication Management Documentation

  • Adherence records to current Uptravi regimen
  • Tolerability assessment without new adverse effects
  • Current dosing information and titration history
  • Documentation of drug-drug interaction management
Clinician Corner: Insurance reviewers look for objective measures of treatment response. Include specific 6-minute walk distances with dates, functional class improvements or stability, and any hemodynamic data from right heart catheterization if performed during the approval period.

Submission Process and Timeline

How to Submit Renewal Requests

Primary Methods:

  1. Cigna Provider Portal: covermymeds.com/main/prior-authorization-forms/cigna/
  2. SureScripts: Through your clinic's electronic health record
  3. Precertification Phone Line: Number on the back of your insurance card

Review Timelines

Request Type Decision Timeline Auto-Approval Rule
Standard Renewal 72 hours Yes - if no response within timeframe
Expedited/Urgent 24 hours Yes - if no response within timeframe

Important: If Express Scripts (Cigna's pharmacy benefit manager) doesn't respond to a completed prior authorization request within the specified timeframe, the request is automatically considered approved.

If Your Renewal Gets Denied

Common Renewal Denial Reasons

Denial Reason How to Address Documentation Needed
Lack of treatment response Provide 6-minute walk data, functional class stability Recent walk tests, specialist notes
Missing background therapy Document combination therapy rationale Treatment history, contraindications
Insufficient monitoring Submit recent assessments Echo results, lab values, clinic visits
Formulary changes Request exception or explore alternatives Medical necessity letter, prior response

Cigna Internal Appeals Process

Level 1 Internal Appeal:

  • Deadline: 180 days from denial
  • Decision Timeline: 30 days (72 hours if expedited)
  • Submit Through: Cigna member portal or appeals address on denial letter

Level 2 Internal Appeal:

  • Available if Level 1 is denied
  • Same timeline and submission process

Annual Plan Changes to Monitor

Formulary Updates

Cigna updates its prescription drug formulary annually. Key changes to watch:

  • Tier Changes: Uptravi moving to higher cost-sharing tier
  • Step Therapy Requirements: New requirements to try alternative PAH therapies first
  • Quantity Limits: Changes to monthly supply limits
  • Specialty Pharmacy Requirements: Mandated use of specific pharmacies

When to Re-verify Coverage

  • January 1st: Annual formulary changes take effect
  • Plan Renewal: If switching Cigna plans or employers
  • Medicare Changes: Annual Medicare Part D formulary updates
Note: Pennsylvania residents with Cigna Medicare Advantage plans should review the Annual Notice of Change (ANOC) document each fall for formulary modifications affecting the following year.

Coverage Gap Bridge Options

Uptravi IV Formulation

If oral therapy is temporarily interrupted, FDA-approved UPTRAVI IV can provide continuity of care. This intravenous formulation:

  • Bypasses hepatic metabolism
  • Requires 12.5% higher dose than oral form
  • Allows seamless switching between formulations
  • Prevents treatment interruptions critical for PAH management

Patient Assistance Programs

Uptravi offers dedicated support programs for eligible patients facing:

  • Insurance coverage gaps
  • High out-of-pocket costs
  • Prior authorization delays
  • Financial hardship

Contact the Uptravi support team immediately if facing any treatment interruption to explore bridge therapy options.

Pennsylvania External Review Process

Pennsylvania's Independent External Review Program provides a powerful appeals option with a 50% success rate for overturning denials.

Eligibility Requirements

  • Plan Type: Fully-insured plans only (not self-funded employer plans)
  • Prior Steps: Must complete Cigna's internal appeal process first
  • Timeline: Request within 4 months of final internal denial

How to Submit

  1. Online Portal: pa.gov/reviewmyclaim
  2. Required Documents:
    • Final Adverse Benefit Determination letter from Cigna
    • Medical records supporting medical necessity
    • Treatment protocols and published guidelines
    • Prior therapy history and outcomes

Decision Timeline

  • Standard Review: 45 days from assignment to Independent Review Organization
  • Expedited Review: 72 hours for urgent medical situations
  • Additional Information: 15 days to submit supporting documents after assignment

Contact for Help: Pennsylvania Insurance Department at 1-877-881-6388

From Our Advocates: We've seen Pennsylvania's external review process work particularly well for specialty medications like Uptravi when the appeal includes comprehensive PAH treatment guidelines and objective response measures. The independent medical reviewers often recognize the critical nature of uninterrupted PAH therapy that insurance company algorithms may miss.

Personal Tracking Template

Renewal Checklist

  • Current authorization expires: ___________
  • Renewal request submitted: ___________
  • Cigna decision received: ___________
  • If denied, internal appeal filed: ___________
  • External review deadline: ___________

Key Contacts

  • PAH Specialist: ________________
  • Cigna Member Services: ________________
  • Specialty Pharmacy: ________________
  • Patient Assistance Program: ________________

Documentation Log

  • Recent 6-minute walk test (date: ______)
  • Functional class assessment (date: ______)
  • Echocardiogram results (date: ______)
  • Specialist visit notes (date: ______)

Understanding Counterforce Health's Role

Counterforce Health specializes in transforming insurance denials into evidence-backed appeals for specialty medications like Uptravi. The platform analyzes denial letters and payer policies to identify specific coverage criteria, then generates targeted appeals with appropriate clinical evidence and procedural requirements. For complex PAH medication appeals involving multiple prior authorizations or external reviews, Counterforce Health's systematic approach can help ensure all payer-specific requirements are met while tracking critical deadlines throughout Pennsylvania's multi-level appeals process.

FAQ

Q: How long does Cigna take to decide on Uptravi renewals? A: Standard renewals receive decisions within 72 hours, expedited requests within 24 hours. If no response is received within these timeframes, the request is automatically approved.

Q: What if my PAH specialist is no longer in-network with Cigna? A: You may need to transfer care to an in-network pulmonary hypertension specialist or request a network exception to continue with your current doctor while maintaining coverage.

Q: Can I get expedited renewal if my current supply is running low? A: Yes, if you're within 15 days of running out and a coverage gap would pose health risks, request expedited processing through your prescriber.

Q: Does Pennsylvania's external review apply to Medicare Advantage Cigna plans? A: No, Medicare Advantage plans follow federal appeal processes. However, you still have internal appeal rights and can escalate to Medicare's independent review process.

Q: What happens if Uptravi moves to a non-covered tier? A: Request a formulary exception with medical necessity documentation. Pennsylvania residents can also use the state external review if the exception is denied.

Q: How do I prove Uptravi is working for my PAH? A: Document functional improvements or stability through 6-minute walk tests, functional class assessments, and absence of PAH-related hospitalizations or disease progression.

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 terms and medical circumstances. Always consult with your healthcare provider and insurance company for specific coverage questions. For assistance with complex appeals in Pennsylvania, contact the Pennsylvania Insurance Department or consider working with Counterforce Health for specialized prior authorization support.

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