Medicare AdvantagePrior AuthHigh impact
Opioid Utilization Program - Morphine Milligram Equivalent (MME) edits (Revised)
Humana·Pain Management, Palliative Care, Oncology +4 more·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Opioid Utilization Program (MME) edits effective January 1, 2025, clarifying prior authorization requirements for opioid prescriptions. For Medicare Advantage members: doses >90 MME daily require prior auth if filled from >2 pharmacies and >2 prescribers; doses >200 MME require clinical review regardless. For LINET members: doses 90-200 MME require prior auth if from multiple pharmacies/prescribers; doses >200 MME always require clinical review. Approval is granted for cancer, sickle cell disease, palliative care, long-term care residents, or when medically necessary per prescriber attestation.
Action Required
By January 1, 2025, the billing and pharmacy teams must: (1) Update prior authorization workflows in the billing system to automatically trigger PA requirements when opioid prescriptions reach >90 MME daily AND are filled from multiple pharmacies (>2) and multiple prescribers (>2) for Medicare Advantage members, or >90 MME for LINET members regardless of provider/pharmacy count; (2) Configure hard edits to require clinical review for all opioid prescriptions >200 MME daily; (3) Train providers and staff on approval criteria, including documentation requirements for cancer diagnosis, sickle cell disease, palliative care status, or medical necessity attestation; (4) Update prior auth request forms to require prescriber attestation of medical necessity when thresholds are exceeded; (5) Ensure pharmacy software is updated to identify all opioid medications listed in Table A (including combination products, excluding cough/cold and buprenorphine/naloxone); (6) Implement regular monitoring (≤3 months) for opioid therapy reassessment per CMS guidelines. Failure to implement these controls will result in denied claims and non-compliance with CMS Part D requirements.