MedicaidPrior AuthHigh impact
Zoladex (goserelin) (New)
Humana·LA · Oncology, OB-GYN, Urology·Medicaid
Effective date
Oct 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicaid (Louisiana) implemented a new Prior Authorization policy for Zoladex (goserelin) effective October 1, 2025, covering four indications: prostate cancer, breast cancer, endometriosis, and endometrial thinning. The policy establishes specific approval criteria, exclusions (including pediatric restrictions and contraindications with other LHRH agents), and varying approval durations by indication. All Zoladex claims in Louisiana Medicaid must now obtain prior authorization before dispensing.
Action Required
By September 15, 2025: Billing team must configure pharmacy billing system to require prior authorization for HCPCS code J9202 (Zoladex/goserelin injection) for all Louisiana Medicaid members. Update prior auth submission templates to capture: (1) member age verification (exclude <18), (2) clinical indication (prostate cancer, breast cancer, endometriosis, or endometrial thinning), (3) for breast cancer: pre/perimenopausal status and hormone receptor (ER/PR) positivity, (4) for endometriosis/endometrial thinning: dosage form confirmation (3.6 mg only), (5) verification of no concomitant LHRH agent use, and (6) for breast cancer: confirmation of no malignant disease progression. Providers must submit prior auth requests before dispensing or claims will be denied. Pharmacy staff should flag any claims for members <18 years old as automatic denials per policy exclusions. Configure renewal parameters: plan year duration for prostate/breast cancer, 6-month for endometriosis, 2-month for endometrial thinning. Train all billing and pharmacy personnel on the four distinct approval pathways and their specific criteria.