MedicaidPrior AuthHigh impact
Remodulin® (treprostinil) (New)
Humana·IN · Cardiology, Pulmonology, Internal Medicine·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 4, 2026
Summary
Humana Indiana Medicaid has established a new prior authorization policy for Remodulin® (treprostinil) effective August 1, 2026. The policy requires prior authorization for pharmacy claims and specifies five clinical criteria that must be met for coverage approval, including confirmed PAH diagnosis via right heart catheterization, WHO Functional Class II-IV status, failed/ruled-out oral calcium channel blockers, disease progression despite maximal therapy, and significant symptoms. This is a NEW policy (1 day old) requiring immediate implementation.
Action Required
By July 15, 2026: Billing team must implement prior authorization requirements for all Remodulin® (treprostinil) claims submitted to Humana Indiana Medicaid. (1) Update billing software/EMR to flag Remodulin prescriptions for mandatory prior auth review before claim submission. (2) Create or modify prior auth submission template to include documentation of: diagnosis of WHO Group I PAH confirmed by right heart catheterization, WHO Functional Class (II, III, or IV), evidence of disease progression despite maximal medical/surgical treatment, documented significant symptoms (dyspnea on exertion, fatigue, angina, syncope), and documentation that oral calcium channel blockers were tried and failed OR considered and ruled out. (3) Notify all providers prescribing Remodulin in Indiana Medicaid patients that prior auth is now required; provide them with the five approval criteria. (4) Establish internal workflow to deny or hold claims lacking required documentation. Do NOT submit Remodulin claims for Indiana Medicaid members without prior authorization approval, as claims will be denied. Route all prior auth requests through Humana's PAL system at www.humana.com/PAL. Note: Policy specifies that initial and renewal approvals are limited to plan year duration; configure system to track approval periods and resubmit for renewal.