Medicare AdvantagePrior AuthMedium impact
Samsca® (tolvaptan) (Revised)
Humana·Internal Medicine, Cardiology, Nephrology +2 more·Medicare Advantage
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
Humana updated its Samsca® (tolvaptan) prior authorization policy for Medicare Advantage members on February 25, 2026. The policy requires prior authorization for tolvaptan use in clinically significant hypervolemic or euvolemic hyponatremia, with mandatory hospital initiation per black box warning. A critical exclusion prohibits use for ADPKD outside FDA-approved REMS programs, and brand requests require documented prior therapy failure or contraindication to generic tolvaptan.
Action Required
By March 15, 2026: Billing team must implement prior authorization workflow for all Samsca® (tolvaptan) and generic tolvaptan claims submitted for Medicare Advantage members. Update billing system to flag claims for prior auth verification before submission. Require providers to document: (1) clinically significant hypervolemic or euvolemic hyponatremia diagnosis with serum sodium <125 mEq/L or symptomatic lower levels resistant to fluid restriction, (2) hospital initiation of therapy with close sodium monitoring, and (3) for brand Samsca requests, prior therapeutic failure or documented intolerance/contraindication to generic tolvaptan. Explicitly deny or route for medical review any claims indicating ADPKD use outside FDA-approved REMS program. Train billing staff to verify member Medicare Advantage coverage and reject any claims lacking required clinical documentation. Failure to obtain prior authorization will result in claim denials.