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HumanaMedicaid · Prior Auth · Medicaid · IN · Oncology, Urology, OB-GYNHigh impact

Zoladex (goserelin) (New)

Act
by Sep 15, 2025
Effective date
Oct 1, 2025
Identified
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.

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What to do

by Sep 15, 2025 · 11 steps
01Billing 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.
02Add clinical review checks for the four covered indications.
03Prostate cancer—verify advanced disease or high recurrence risk.
04Breast cancer—verify pre/perimenopausal status AND ER/PR+ diagnosis.
05Endometriosis—verify diagnosis AND confirm 3.6 mg dosage only.
06Endometrial thinning—verify endometrial ablation scheduled AND confirm 3.6 mg dosage only.
07For 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).
08Obtain prior auth before claim submission.
09Update encounter forms and provider templates.
10Communicate with oncology, urology, and ob-gyn providers.
11Without prior auth, claims will be denied and may require resubmission or patient appeals.

Codes mentioned

J9202

Original notice

Zoladex (goserelin) (New)
mcp.humana.com · Always check the source before changing claims.
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Related changes

See all Humana changes →
Zoladex (goserelin) (Revised)MediumEffective Aug 27, 2025 · MedicaidZoladex (goserelin) (New)HighEffective Oct 1, 2025 · MedicaidZoladex (goserelin) (Revised)MediumEffective Oct 1, 2025 · MedicaidZoladex (goserelin) (Revised)MediumEffective Oct 1, 2025 · MedicaidBrowse every Humana change in the policy list

Related policy hubs

Humana policiesIN policy changesOncologyUrologyOB-GYNCode J9202

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