Drug Management Program-Opioid Program (Revised)

By July 23, 2025: Billing and pharmacy teams must immediately implement the revised Drug Management Program-Opioid Program edits in all claims processing systems. REQUIREMENTS: (1) Update point-of-sale (POS) system to enforce new beneficiary-level edits based on revised MME thresholds (90 mg average daily) and prescriber/pharmacy count criteria (3+ prescribers AND 3+ pharmacies, OR 5+ prescribers); (2) Configure system to apply MME dose limits, prescriber restrictions, and pharmacy restrictions to flagged members after case management review; (3) Ensure system excludes specified products from MME calculations (buprenorphine excluded from MME but included in prescriber/pharmacy counts; opium tincture, cough/cold products, injectable opioids excluded from both); (4) Implement member exclusion workflows for cancer pain, hospice, palliative/end-of-life care, long-term care residents, assisted living facility residents (with single-pharmacy contract), and sickle cell patients—requiring prescriber attestation if not documented in Humana system; (5) Program edit durations as 12 months initial (extendable to 24 months if at-risk behavior continues); (6) Create processes for member/prescriber/pharmacy requests to adjust or remove restrictions, with documented justification (prescriber attestation, health condition changes, successful appeals); (7) Configure re-evaluation protocols if members reappear on Overutilization Monitoring System (OMS) reports after edit removal; (8) Train billing, claims, and prior authorization staff on new criteria and exemption requirements. CONSEQUENCES: Failure to implement will result in claim denials for members with active quantity/prescriber/pharmacy limits, member complaints for inappropriate claim rejections, and compliance violations with Humana's Medicare drug management requirements.