MedicaidPrior AuthMedium impact
Zoladex (goserelin) (New)
Humana·OH · Oncology, OB-GYN, Urology +1 more·Medicaid
Effective date
Oct 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicaid Ohio has implemented a new prior authorization policy for Zoladex (goserelin) effective October 1, 2025, covering four indications: prostate cancer, breast cancer, endometriosis, and endometrial thinning. Each indication has specific approval criteria, exclusions, and approval duration limits (ranging from 2 months to plan year duration). All Zoladex requests for Ohio Medicaid members now require prior authorization before dispensing.
Action Required
By October 1, 2025: Billing team and providers must implement prior authorization process for all Zoladex (goserelin) claims for Humana Medicaid Ohio members. (1) Update billing system to flag all J9155 claims for Humana Medicaid Ohio requiring prior auth submission before claim processing. (2) Create prior auth request workflow with indication-specific criteria: for prostate cancer - verify advanced diagnosis or high recurrence risk; for breast cancer - confirm pre/perimenopausal status AND ER/PR+ hormone receptor status; for endometriosis - confirm 3.6mg dosage only and 6-month approval window; for endometrial thinning - confirm scheduled endometrial ablation and 3.6mg dosage only and 2-month approval window. (3) Implement exclusion checks: exclude pediatric members <18 years, exclude concomitant LHRH agents, exclude abnormal vaginal bleeding of unknown etiology (for breast cancer/endometriosis/endometrial thinning), exclude disease progression (for breast cancer). (4) Update provider order entry forms and encounter templates to require specific diagnosis and clinical justification. (5) Establish timeline to submit prior auth requests to Humana PAL portal (www.humana.com/PAL) before dispensing medication. Claims submitted without prior authorization will be denied. Providers should verify current coverage status for each claim before submission.