Opsumit (macitentan) 1647-A SGM P2023
Defines coverage and authorization criteria for Opsumit (macitentan) for treatment of pulmonary arterial hypertension (PAH, WHO Group 1) including prescriber specialty requirements, diagnostic confirmation criteria, continuation criteria, and statement that non-FDA/compendial uses are investigational.
No material change
Coverage Summary
Coverage stance: covered_with_criteria. Scope summary: This policy defines coverage and authorization criteria for Opsumit (macitentan) for treatment of pulmonary arterial hypertension (PAH, WHO Group 1). Authorization of 12 months may be granted when the specified diagnostic, prescriber specialty, and continuation criteria are met. Uses of Opsumit outside the FDA-approved/compendial indication for PAH (WHO Group 1) are considered investigational/not medically necessary.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.