Medicare AdvantagePrior AuthMedium impact
Zusduri (mitomycin)
Humana·KY, SC · Oncology, Urology·Medicaid
Effective date
Aug 27, 2025
We identified it
Jun 25, 2026
Summary
Humana has established a new prior authorization policy for Zusduri (mitomycin) intravesical treatment effective August 27, 2025, covering Medicare and Medicaid members in Kentucky and South Carolina. The policy requires prior authorization for initial treatment (maximum 6 doses over 6 months) and renewal periods for patients with recurrent low-grade intermediate-risk non-muscle invasive bladder cancer, with specific clinical criteria and exclusions that must be met for approval.
Action Required
By August 27, 2025: Billing and clinical teams must implement prior authorization requirements for all Zusduri (mitomycin) intravesical kit and Sterile Hydrogel For Zusduri intravesical solution claims. (1) Update billing system to flag these medications as requiring prior authorization before claim submission. (2) Establish internal checklist for prior auth verification: confirm member has LG-IR-NMIBC diagnosis, documented recurrent disease, and has not exceeded 6 prior doses of Zusduri. (3) Screen for exclusion criteria (bladder perforation) before authorization requests. (4) Route authorization requests through Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for applicable coding information. (5) Instruct providers to submit prior auth requests early, as claims will be DENIED without prior authorization approval. (6) For Kentucky and South Carolina Medicaid members specifically, ensure claims are submitted with correct line of business coding. (7) Document all prior authorizations in member records; approvals are limited to 6 months/6 doses per authorization period. Without prior auth compliance, all Zusduri claims will be rejected.