Medicare AdvantagePrior AuthHigh impact
Abuse Deterrent Oxycodone tablets (RoxyBond,Oxaydo, generics)
Humana·Pain Management, Palliative Care, Internal Medicine +2 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage is updating its prior authorization policy for abuse-deterrent oxycodone tablets (RoxyBond, Oxaydo, and generics), effective January 1, 2026. The policy requires prior authorization for all abuse-deterrent oxycodone oral tablets and mandates that patients have failed or been intolerant to at least two alternative immediate-release opioids before approval. This is a revision to the original July 27, 2022 policy.
Action Required
By December 31, 2025: Billing team must implement prior authorization requirements in the billing system for all prescriptions of RoxyBond, Oxaydo, and generic abuse-deterrent oxycodone tablets for Medicare Advantage members. Update claim submission workflows to require documentation of: (1) confirmation that patient has pain severe enough to require opioid medication and alternative treatments are inadequate, and (2) evidence of previous treatment failure, contraindication, or intolerance to at least TWO of the following: non-abuse-deterrent oxycodone, hydromorphone, or morphine. Add alerts to encounter forms and electronic prescription systems reminding providers to obtain prior authorization before prescribing. Train billing staff on the two-criterion approval requirements. Without prior authorization, claims will be denied for Medicare Advantage members.