MedicaidPrior AuthMedium impact
Zusduri (mitomycin) (New)
Humana·OH · Oncology, Urology·Medicaid
Effective date
Oct 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicaid-Ohio has established a new prior authorization requirement for Zusduri (mitomycin) intravesical instillation therapy, effective October 1, 2025. This is a brand-new pharmacy coverage policy for a specialized bladder cancer treatment. Billing teams must implement prior authorization workflows and ensure claims include documentation of recurrent low-grade intermediate-risk non-muscle invasive bladder cancer (LG-IR-NMIBC) diagnosis, no prior Zusduri therapy, and absence of bladder perforation.
Action Required
By September 15, 2025: Billing team must implement prior authorization process for Zusduri (mitomycin) intravesical kit and Sterile Hydrogel for Zusduri in the billing system for all Humana Medicaid-Ohio members. Update claim submission workflows to require prior auth submission before dispensing. Providers and pharmacy staff must verify at the point of service that: (1) member has documented diagnosis of LG-IR-NMIBC, (2) member has documented recurrent disease, (3) member has not received prior Zusduri therapy (max 6 doses lifetime), and (4) member does not have bladder perforation. Route all Zusduri requests to clinical review team; initial approval covers 6 months (maximum 6 doses) or as determined by clinical review. Claims submitted without prior authorization will be denied. Update pharmacy system and provider ordering platforms to flag Zusduri as requiring prior auth.