Opioid Utilization Program - Morphine Milligram Equivalents (MME) edits (Revised)

By December 15, 2024: Billing and prior authorization teams must update internal systems and workflows to implement the revised MME thresholds for all opioid medications (18 medications listed in Table A, including morphine, oxycodone, hydrocodone, fentanyl, methadone, buprenorphine, tramadol, and others). Immediately: Configure billing software to automatically require prior authorization for cumulative daily opioid doses exceeding 50 mg MME for all Florida Medicaid claims. For doses 50-250 mg, enable auto-approval (PPS eligible) without prior auth. For doses exceeding 250 mg, route to clinical review team. Update prior authorization request forms to capture prescriber attestation of medical necessity and verify member eligibility for exception criteria (active cancer diagnosis, sickle-cell disease, palliative care, long-term care facility residence). Train providers on the new thresholds and exception pathways. Establish process to deny or request additional information for prescriptions exceeding limits without documented qualifying criteria. Update patient education materials explaining opioid utilization controls. Failure to implement prior authorization requirements will result in claim denials and potential compliance violations with Humana Florida Medicaid requirements.