MedicaidPrior AuthHigh impact
Zoladex (goserelin) (New)
Humana·IN · Oncology, Urology, OB-GYN·Medicaid
Effective date
Oct 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicaid Indiana has issued a NEW prior authorization policy (effective October 1, 2025) for Zoladex (goserelin) covering four indications: prostate cancer, breast cancer, endometriosis, and endometrial thinning. This is a NEW policy requiring prior authorization for all Zoladex claims with specific approval criteria and exclusions for each indication. Billing teams must implement prior auth requirements immediately to prevent claim denials.
Action Required
By September 15, 2025: Billing team must configure billing system to require prior authorization for HCPCS code J9202 (Goserelin implant, per 3.6 mg) for all Humana Medicaid Indiana claims. Add clinical review checks for the four covered indications: (1) Prostate cancer—verify advanced disease or high recurrence risk; (2) Breast cancer—verify pre/perimenopausal status AND ER/PR+ diagnosis; (3) Endometriosis—verify diagnosis AND confirm 3.6 mg dosage only; (4) Endometrial thinning—verify endometrial ablation scheduled AND confirm 3.6 mg dosage only. For ALL indications, flag and DENY claims if: concomitant LHRH agents present, abnormal vaginal bleeding of unknown etiology (breast, endometriosis, endometrial thinning), member <18 years old, or disease progression documented (breast cancer only). Obtain prior auth before claim submission. Update encounter forms and provider templates. Communicate with oncology, urology, and ob-gyn providers. Without prior auth, claims will be denied and may require resubmission or patient appeals.