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HumanaMedicare Advantage · Prior Auth · Medicare Advantage · Pain Management, Palliative Care, OncologyHigh impact

Long-Acting Opioids (New)

Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Oct 2, 2026

Summary

Effective January 1, 2027, Humana Medicare Advantage implements a new prior authorization policy for 13 long-acting opioid medications. All long-acting opioid prescriptions now require prior authorization and must meet four strict criteria: persistent non-acute pain requiring around-the-clock treatment, severe enough to warrant opioids, failure/inability to use immediate-release opioids, and failure/inability to use morphine ER or fentanyl patch. This represents a significant tightening of opioid access under Medicare Advantage.

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What to do

by Dec 31, 2026 · 5 steps
01Billing team must update all billing software and EHR systems to flag all long-acting opioid prescriptions for mandatory prior authorization before claims submission.
02Providers must be notified that ALL prescriptions for the 13 covered long-acting opioids (Belbuca, Hysingla, Nucynta ER, OxyContin, Xtampza ER, morphine ER, oxymorphone ER, oxycodone ER, hydrocodone ER, hydromorphone ER, and tapentadol ER) require prior auth—no exceptions.
03Front desk and authorization staff must be trained to collect required documentation: evidence of persistent pain lasting >3 months, documentation that non-opioid alternatives (NSAIDs, PT, CBT) were tried or contraindicated, proof that immediate-release opioids were tried/failed/contraindicated, and proof that morphine ER or fentanyl patch were tried/failed/contraindicated.
04Update prior authorization request forms to capture all four criteria explicitly.
05Establish workflow to route all long-acting opioid requests to medical reviewers before approval.
If missed: Failure to obtain prior authorization will result in claim denials for all affected medications.

Original notice

Long-Acting Opioids (New)
mcp.humana.com · Always check the source before changing claims.
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Humana policiesPain ManagementPalliative CareOncology

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