Medicare AdvantagePrior AuthHigh impact
Opioid Utilization Program - Concurrent Use of Opioids and Benzodiazepines (COB) edits (Revised)
Humana·SC, OK, VA · Pain Management, Psychiatry, Pharmacy +2 more·Medicaid
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana has revised its Opioid Utilization Program policy to mandate prior authorization for ALL concurrent use of opioids and benzodiazepines (both new and existing patients) across Medicare, Medicaid (SC, OK, VA), and LINET plans, effective January 1, 2025. The policy creates point-of-sale edits with soft rejects (Virginia Medicaid) or hard rejects (South Carolina Medicaid) that require pharmacist override codes or prior authorization approval, with limited exceptions for sickle cell disease, active cancer, hospice, long-term care residents, and cases where providers attest to benefit outweighing risks.
Action Required
By January 1, 2025: (1) Billing and clinical teams must immediately review all active patients currently on concurrent opioid and benzodiazepine therapy to identify those requiring prior authorization or pharmacist intervention. (2) Pharmacy and medical billing staff must update pharmacy management systems and prior authorization workflows to flag all new opioid prescriptions when benzodiazepines are detected in patient profiles (and vice versa). (3) Providers must be notified to expect point-of-sale rejections for concurrent opioid-benzodiazepine prescriptions and must be prepared to either: submit prior authorization requests, qualify patients for exceptions (sickle cell, cancer, hospice, LTC, or documented benefit-risk attestation with patient education), or provide pharmacist override codes (VA Medicaid only). (4) For South Carolina Medicaid patients, prepare for hard rejects only (no soft reject override option) and establish prior auth submission protocols. (5) For Virginia Medicaid patients, train pharmacy staff on PPS code overrides (AT, DE, M0, MP, PE, P0, R0, SW, 1A, 1B, 1D, 1F, 1G, 4A, 4B, 4D). (6) Update patient education materials and pharmacy consultation templates to document patient counseling on opioid-benzodiazepine risks. Failure to implement prior authorization processes will result in pharmacy claim denials and treatment delays.