Medicare AdvantagePrior AuthMedium impact
Ongentys® (opicapone) (Revised)
Humana·Neurology, General Practice, Internal Medicine·Medicare Advantage
Effective date
Aug 27, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Ongentys (opicapone) pharmacy coverage policy on August 27, 2025, clarifying prior authorization requirements for this Parkinson's disease medication. The policy requires members to meet five specific clinical criteria including Parkinson's disease diagnosis, concurrent carbidopa/levodopa use, documented "off" episodes, and prior trial or contraindication to entacapone-containing medications before coverage is approved.
Action Required
By September 15, 2025: Billing team must update prior authorization workflows to enforce the five clinical criteria for Ongentys (opicapone) claims submitted to Humana Medicare Advantage plans. Update authorization request templates to capture: (1) Parkinson's disease diagnosis confirmation, (2) current carbidopa/levodopa dosing, (3) documentation of "off" episodes, (4) confirmation combination therapy will be used, and (5) evidence of entacapone trial or contraindication. Providers must include this documentation when submitting authorization requests through Humana's system or claims will be delayed pending medical records review. Train front desk and clinical staff to collect entacapone trial history before appointment to expedite authorizations.