MedicaidPrior AuthHigh impact
Virginia Short Acting Opioid Days Supply (Revised)
Humana·VA · Pain Management, Palliative Care, Oncology +1 more·Medicaid
Effective date
Jul 1, 2025
We identified it
Jun 25, 2026
Summary
Effective July 1, 2025, Humana Virginia Medicaid implements strict quantity limits on short-acting opioids: members can receive a maximum 7-day supply without prior authorization, with subsequent claims limited to 7 days (14 days total every 60 days) and capped at 60 MME per day. Prior authorization is required for any claims exceeding these thresholds or for members without qualifying diagnoses (HIV/AIDS, cancer, chronic pain conditions, palliative/hospice care, or long-term care residents).
Action Required
By June 28, 2025: (1) Billing team must update pharmacy claims processing system to enforce 7-day supply limits and flag claims exceeding 60 MME/day for automatic prior authorization submission. (2) Configure system to calculate 60-day intervals and reject or hold claims exceeding 14-day total per cycle without prior auth. (3) Update claim denial response templates to explain new quantity limits and MME thresholds. (4) Providers must review opioid prescribing workflows and ensure prescriptions align with policy limits. (5) Front desk staff must flag opioid refill requests for verification against the 60-day cycle. Without these updates, claims will be systematically denied or delayed, and patient access to medications will be disrupted. Establish prior authorization submission process for claims not meeting automatic approval criteria, noting that approval duration varies by diagnosis (3 months for chronic pain/HIV/AIDS; 6 months for cancer/sickle cell/end-of-life care).