Medicare AdvantagePrior AuthMedium impact
Revatio® (sildenafil) suspension (Revised)
Humana·Pulmonology, Cardiology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2021
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for Revatio® (sildenafil) oral powder suspension for pulmonary arterial hypertension (PAH). The policy requires prior authorization and mandates that members meet two key criteria: confirmed PAH diagnosis via right heart catheterization (WHO Group I) AND prior therapy, contraindication, or intolerance to another oral PDE5 inhibitor. This is a policy clarification/reinforcement effective January 1, 2021, with the most recent revision dated December 17, 2025.
Action Required
By December 31, 2025: Billing team must verify that all Revatio® (sildenafil) suspension claims are submitted with prior authorization. Before processing claims, confirm patient documentation includes: (1) confirmation of PAH diagnosis by right heart catheterization (WHO Group I), AND (2) evidence of prior therapy, contraindication, or intolerance to another oral PDE5 inhibitor (sildenafil tablets or tadalafil). Update claims processing workflow to check for both criteria. Route any claims missing either criterion back to the provider for additional documentation. Failure to obtain prior authorization or verify these two criteria will result in claim denials. Pharmacy billing staff should coordinate with clinical staff to ensure all PA requests include right heart catheterization documentation.