CurrentCignaPolicy N/A

Uptravi (selexipag) Drug Quantity Management — Quantity limits and override criteria

Defines drug quantity limits and override criteria for Uptravi (selexipag) tablets and titration packs for Cigna-administered health benefit plans; affects prescribers and pharmacy benefit administrators processing Uptravi prescriptions.

Policy Summary

PayerCigna

PolicyUptravi (selexipag) Drug Quantity Management — Quantity limits and override criteria

Policy CodePolicy N/A

Change TypeRevised and clarified quantity limits/overrides

Effective DateJan 8, 2025

Next Review DateJan 8, 2025

Key ActionWhen submitting Uptravi prescriptions, ensure quantity requests meet Drug Quantity Management limits or documented override criteria (e.g., one-time 140-tablet override for 200 mcg initiation or 200-tablet titration pack allowance per 365 days).

SourceLink

POLICY UPDATE CHANGES

Changed the quantity limit for the Uptravi Titration Pack to 200 tablets (1 pack) per 365 days and clarified override criteria to permit approval when reinitiating therapy or requiring prolonged titration.

Clarified override criteria for Uptravi 200 mcg tablets to allow a one-time override for 140 tablets when initiating therapy or requiring prolonged titration.

60maximum tablets per retail Rx

180maximum tablets per home delivery Rx

200titration pack tablets

200/365d

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Coverage Criteria

Quantity limits and override criteria

Covered as medically necessary when the Drug Quantity Management rules or listed overrides are met; any other exception is not medically necessary.

Titration Pack Quantity Limit: Titration pack (140 x 200 mcg + 60 x 800 mcg = 200 tablets) is limited to 200 tablets (1 pack) per 365 days.200 tablets per 365 days

Per-policy per-365-day limit; overrides allowed as specified below.

Titration Pack Overrides

Approve an override for an additional 200 tablets (1 titration pack) at retail or home delivery if the patient is reinitiating therapy with Uptravi.
One-time override permitted under this criterion.
Approve an override for an additional 200 tablets (1 titration pack) at retail or home delivery if the prescriber documents the patient requires a prolonged dose-titration period.
One-time override permitted under this criterion.

200 mcg tablet quantity: For initiation of therapy, approve an override for 140 tablets at retail or home delivery.140 tablets

Also approve 140 tablets if prescriber documents a prolonged dose-titration period; one-time override per initiation or prolonged titration.

400–1600 mcg tablet strengths: No overrides recommended for 400 mcg, 600 mcg, 800 mcg, 1,000 mcg, 1,200 mcg, 1,400 mcg, and 1,600 mcg tablets.

Standard quantity limits apply (60 tablets retail / 180 tablets home delivery); exceptions beyond listed overrides are considered not medically necessary.

No overrides are recommended for the 400 mcg, 600 mcg, 800 mcg, 1,000 mcg, 1,200 mcg, 1,400 mcg, and 1,600 mcg tablet strengths. Requests for these strengths must adhere to the standard Drug Quantity Management limits; exceptions beyond the overrides explicitly listed in the criteria are not provided and therefore are not permitted.

If a requested quantity exceeds the Drug Quantity Management limits and does not meet one of the specified override conditions (for example, reinitiating therapy or documented need for prolonged titration for the titration pack or 200 mcg tablets), the request is considered not medically necessary and should be denied. The policy directs that coverage will be determined by the criteria when the Drug Quantity Management rule is not met at point of service.

Coding and Dosing Details

Drug forms and supply (no explicit billing codes provided)NDC

NDC not specified

Document lists tablet strengths (200-1600 mcg) and titration pack but does not provide NDCs

Titration dosing schedule — Uptravi (selexipag)

Starting dose200 mcg twice daily (BID)

Titration incrementIncrease by 200 mcg BID, usually at weekly intervals

Maximum doseUp to 1,600 mcg twice daily (BID)

Tolerability guidanceIf dose not tolerated, reduce to last tolerated dose; do not split, crush, or chew tablets

Missed dosesIf a dose is missed, take as soon as possible unless next dose due within 6 hours; if missed ≥3 days, restart at lower dose and retitrate

Provider Actions, Limits, and Authorization

Prior Authorization

Drug quantity limits and override summary

Retail: maximum 60 tablets per prescription. Home delivery: maximum 180 tablets per prescription. For the Uptravi titration pack (140 x 200 mcg + 60 x 800 mcg = 200 tablets), limit is 200 tablets (1 pack) per 365 days. Overrides may be granted as outlined below; quantity limits not met at point of service may trigger coverage review or denial.

Affected products: Uptravi (selexipag) tablets, strengths 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1000 mcg, 1200 mcg, 1400 mcg, 1600 mcg; Titration Pack = 200 tablets (140x200 mcg + 60x800 mcg).
Retail max: 60 tablets per Rx.
Home delivery max: 180 tablets per Rx.
Titration pack: 200 tablets (1 pack) per 365 days.

Documentation Required

Supporting documentation principles

Coverage determinations consider the applicable benefit plan terms, relevant laws/regulations, collateral materials (including this coverage policy), and the specific clinical facts. Documentation should support the medical necessity of quantity overrides (e.g., reason for reinitiation, clinical rationale for prolonged titration, prescriber statement). Medical directors may exercise clinical judgment when reviewing requests.

Definitions

Uptravi Titration Pack — description

Pack contents1 bottle of 140 x 200 mcg tablets + 1 bottle of 60 x 800 mcg tablets (total 200 tablets)

PurposePacked supply used to support weekly upward titration from 200 mcg BID to higher tolerated doses during initiation

Used in dosing examplesProvides the 140 x 200 mcg tablets required during weeks with mixed 200 mcg and 800 mcg dosing and 60 x 800 mcg for interim higher-strength dosing

Packaging note200 mcg tablets are also supplied in bottles of 60 or 140; titration pack combines those strengths for convenience

Background

Uptravi (selexipag) is a prostacyclin receptor agonist indicated for the treatment of pulmonary arterial hypertension (WHO Group 1) to delay disease progression and reduce the risk of hospitalization. Recommended initiation is 200 mcg twice daily (BID), with weekly titration increments of 200 mcg BID up to a target maintenance dose of 1,600 mcg twice daily. Titration is commonly managed using multiple tablet strengths and a titration pack that contains 140 x 200 mcg tablets and 60 x 800 mcg tablets (total 200 tablets) to support safe dose escalation.