MedicaidPrior AuthHigh impact
Opioid Utilization Program - Morphine Milligram Equivalent (MME)
Humana·VA · Pain Management, Oncology, Palliative Care +3 more·Medicaid
Effective date
Jul 1, 2025
We identified it
Jun 24, 2026
Summary
Humana Virginia Medicaid now requires prior authorization for all opioid medications when daily morphine milligram equivalent (MME) exceeds 90 mg, with specific exemptions for cancer, palliative care, hospice, long-term care facilities, or medically necessary cases with prescriber attestation.
Action Required
By July 1, 2025: Billing team must update prior authorization workflows for Virginia Medicaid opioid prescriptions exceeding 90 MME daily. Providers must document qualifying diagnoses (cancer pain, sickle cell disease, palliative care, end-of-life care, hospice care) or attest medical necessity with Virginia BOM compliance. Update EMR templates to capture required documentation. Claims without proper authorization will be denied.