MedicaidPrior AuthHigh impact
Opioid Utilization Program - Morphine Milligram Equivalents (MME) edits (Revised)
Humana·SC · Pain Management, Palliative Care, Oncology +4 more·Medicaid
Effective date
Feb 1, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Opioid Utilization Program (MME edits) for South Carolina Medicaid, effective February 1, 2025. The policy enforces quantity limits and prior authorization requirements for all opioid medications based on morphine milligram equivalents (MME), with different thresholds for opioid-naive patients (>90 MME daily or >5 days supply) and opioid-tolerant patients (maximum 30-day supply). Billing teams must implement prior authorization workflows for doses exceeding these limits unless specific clinical criteria are met (cancer, sickle-cell disease, palliative care, substance use disorder treatment, long-term care residence, or prescriber medical necessity attestation).
Action Required
By February 1, 2025: Billing team must implement the following changes in the claims processing system and pharmacy billing software: (1) Configure point-of-sale (POS) edits to require prior authorization for all opioid-containing medications (per Table A: buprenorphine, butorphanol, codeine, dihydrocodone, fentanyl, hydrocodone, hydromorphone, levorphanol tartrate, meperidine, methadone, morphine, nalbuphine, opium, oxycodone, oxymorphone, pentazocine, tapentadol, tramadol) when daily cumulative MME exceeds 250 mg for all patients, or exceeds 90 MME for opioid-naive patients on first fill, or exceeds 5-day supply for opioid-naive acute pain, or exceeds 30-day supply for opioid-tolerant patients; (2) Update claims system to identify opioid-naive status (no paid opioid claim in past 60 days) and opioid-tolerant status (paid opioid claim within past 60 days) automatically; (3) Configure automatic prior authorization approval when prescriber attests medical necessity or when applicable clinical exceptions apply (active cancer diagnosis, sickle-cell disease, palliative care, long-term care facility residence, medication-assisted treatment for substance use disorder); (4) Train billing staff and claims reviewers on new MME thresholds and documentation requirements; (5) Update provider notices and billing workflows to explain prior authorization requirements at point of fill. Providers must attest to medical necessity when dosing exceeds thresholds. Failure to implement these edits will result in non-compliance with Humana's Medicaid pharmacy coverage policy and potential claims payment issues.