Medicare AdvantagePrior AuthHigh impact
Drug Management Program-Opioid Program (Revised)
Humana·Pain Management, Psychiatry, Internal Medicine +3 more·Pharmacy
Effective date
Jul 22, 2026
We identified it
Jul 22, 2026
Summary
Humana has revised its Drug Management Program-Opioid Program (effective July 22, 2026) to implement beneficiary-level pharmacy point-of-sale edits for Medicare members at risk of opioid/benzodiazepine abuse. The policy establishes clinical criteria triggering reviews (e.g., ≥90 MME daily average plus multiple prescribers/pharmacies), allows restrictions on MME limits, prescribers, and pharmacies, and includes exclusions for cancer pain, hospice, and palliative care. Billing teams must understand these edits may cause claim denials or rejections if members are flagged and limitations are applied.
Action Required
By July 22, 2026: Billing team and prior authorization staff must (1) update internal tracking systems to recognize when Humana applies beneficiary-level edits to opioid and benzodiazepine claims for at-risk Medicare members; (2) train staff on the minimum clinical criteria that trigger reviews (≥90 MME + 3+ prescribers/3+ pharmacies, or 5+ prescribers, or ≥7 prescribers/pharmacies, or prior opioid overdose diagnosis); (3) prepare to handle claim rejections or denials when members hit MME limits, pharmacy limitations, or prescriber restrictions imposed by Humana; (4) establish a process to request attestation from prescribers for exclusion criteria (cancer pain, hospice, palliative care, long-term care, assisted living, sickle cell) when necessary to bypass edits; (5) document appeals and adjustment requests (prescriber-initiated MME changes, member-initiated pharmacy changes, exclusion attestations) and resubmit claims as appropriate. Failure to understand and process these edits will result in unexpected claim denials and patient access delays.