Medicare AdvantagePrior AuthMedium impact
Remodulin® (treprostinil) (Revised)
Humana·SC · Pulmonology, Cardiology·Medicaid
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana has updated prior authorization requirements for Remodulin (treprostinil) injection for pulmonary arterial hypertension treatment under Medicare and Medicaid plans in South Carolina. The policy requires six specific criteria to be met including WHO Group I PAH diagnosis confirmed by right heart catheterization and failure of oral calcium channel blockers.
Action Required
By January 1, 2026: Billing team must update prior authorization workflows for Remodulin (treprostinil) injections for South Carolina Humana Medicare and Medicaid patients. Ensure all six criteria are documented before submission: WHO Group I PAH diagnosis with right heart catheterization confirmation, WHO Functional Class II-IV, progression despite maximal treatment, significant symptoms, failed/contraindicated calcium channel blockers, and BvsD coverage determination if required. Claims will be denied without proper prior authorization.