Medicare AdvantagePrior AuthLow impact
Adempas® (riociguat) (Revised)
Humana·Pulmonology, Cardiology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has revised their prior authorization policy for Adempas (riociguat), used to treat pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. The policy requires specific diagnostic criteria and documentation to be met before approval, with plan year duration approvals.
Action Required
By January 1, 2026: Review patients currently prescribed Adempas (riociguat) for pulmonary hypertension conditions. Ensure prior authorization requests include required diagnostic documentation: right heart catheterization confirmation for PAH (WHO Group 1) or evidence of inoperable/persistent CTEPH (WHO Group 4) after surgical treatment. Update prior auth request templates to include these specific criteria. Claims may be denied without proper prior authorization.