Medicare AdvantagePrior AuthLow impact
Opsumit® (macitentan)/Opsynvi® (macitentan and tadalfil)
Humana·Cardiology, Pulmonology, Internal Medicine·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/tadalafil) used to treat pulmonary arterial hypertension. Members must have WHO Group 1 PAH confirmed by right heart catheterization to qualify for coverage.
Action Required
Before January 1, 2026: Billing team must update prior authorization workflows for Opsumit and Opsynvi prescriptions. Providers must obtain prior auth by confirming patient has WHO Group 1 pulmonary arterial hypertension diagnosed via right heart catheterization. Update pharmacy benefit management system to flag these medications for prior authorization review.