Medicare AdvantagePrior AuthMedium impact
Winrevair™ (sotatercept-csrk)
Humana·Pulmonology, Cardiology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage is implementing a new Prior Authorization policy for Winrevair (sotatercept-csrk), a subcutaneous injection for pulmonary arterial hypertension, effective January 1, 2026. Prior authorization is required for all new prescriptions, with specific clinical criteria that must be met: confirmed PAH diagnosis via right heart catheterization, WHO functional class II-IV symptoms, and stable background PAH therapy (either combination therapy or monotherapy due to intolerance).
Action Required
By December 31, 2025: Billing and clinical teams must implement prior authorization requirement for Winrevair (sotatercept-csrk) in the billing system for all Medicare Advantage members. Update encounter templates and order entry systems to flag this medication for prior authorization review. Establish internal process to collect and verify the three required clinical criteria before submitting authorization requests to Humana: (1) right heart catheterization confirmation of WHO Group 1 PAH, (2) documentation of WHO functional class II-IV, and (3) confirmation of stable background PAH therapy. Train providers and staff on the new authorization requirement. Without prior authorization, Winrevair claims will be denied by Humana Medicare Advantage plans.