Medicare AdvantagePrior AuthMedium impact
Opsumit® (macitentan)/Opsynvi® (macitentan and tadalfil) (New)
Humana·Pulmonology, Cardiology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage now requires prior authorization for Opsumit (macitentan) and Opsynvi (macitentan and tadalafil) used to treat pulmonary arterial hypertension. The policy establishes specific criteria including confirmed PAH diagnosis via right heart catheterization and prior therapy requirements for Opsynvi.
Action Required
Before January 1, 2026: Billing team must update prior authorization requirements for Opsumit and Opsynvi prescriptions for Humana Medicare Advantage patients with pulmonary arterial hypertension. Providers must document PAH diagnosis confirmed by right heart catheterization and for Opsynvi requests, document prior therapy with PDE-5 inhibitors or Adempas plus endothelin receptor antagonists. Update EMR templates to include required criteria documentation.