Medicare AdvantageCoverageHigh impact
Opioid Days' Supply Limitation (Revised)
Humana·Pain Management, Palliative Care, Pharmacy·Medicare Advantage
Effective date
Oct 30, 2024
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its opioid days' supply limitation policy effective October 30, 2024. The policy enforces strict quantity limits: opioid-naive patients are limited to 7 days' supply for acute pain, and opioid-tolerant patients are limited to 30 days' supply for non-acute pain (31 days for long-term care residents). Multiple clinical exceptions exist for cancer, sickle-cell disease, palliative care, and other qualifying diagnoses. Billing teams must ensure claims comply with these limits or face denials at point-of-sale.
Action Required
REQUIREMENTS: By November 15, 2024: Billing and pharmacy staff must review and update all opioid prescription processing workflows to enforce the revised days' supply limits. (1) Billing team: Configure billing software to flag any opioid fills exceeding 7 days for opioid-naive patients or 30 days for opioid-tolerant patients. (2) Providers: Document opioid-naïve vs. opioid-tolerant status clearly on all opioid prescriptions; reference claim history within past 108 days to determine status. (3) Prior authorization reviewers: Apply clinical exception criteria when providers request supply beyond limits—verify active cancer diagnosis, sickle-cell disease, palliative care status, LTC facility residence, or MED dose medical necessity attestation before approval. (4) Front-desk/pharmacy staff: Verify eligible ICD-10 diagnosis codes on file that support pain management exceptions. (5) All staff: Do NOT approve opioid fills for patients concurrently receiving medication-assisted addiction treatment. Failure to enforce these limits will result in automatic claim denials and point-of-sale rejections for non-compliant prescriptions. This is a quantity limit policy subject to CMS PQA High Dose Opioid Use measures, and non-compliance may impact plan quality ratings.