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Zoladex (goserelin) (Revised)
Act
by Sep 27, 2025
Effective date
Aug 27, 2025
Identified
Jun 25, 2026
Summary
Humana revised its Zoladex (goserelin) prior authorization policy effective August 27, 2025, affecting pharmacy coverage for prostate cancer, breast cancer, endometriosis, and endometrial thinning across Medicare and four Medicaid state programs (Florida, Kentucky, South Carolina, Virginia). The policy maintains prior authorization requirements with specific clinical criteria, dosage restrictions (3.6 mg only for endometriosis and endometrial thinning), and exclusions for concomitant LHRH agents and pediatric patients. Billing teams must verify member eligibility against these updated criteria before claim submission to avoid denials.
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What to do
by Sep 27, 2025 · 10 steps
01Billing team must update prior authorization workflows to reflect the revised Zoladex policy requirements.
02Update billing software to flag all Zoladex (J9202) claims for prior authorization review.
03Implement clinical criteria validation in the authorization request process: verify member diagnosis matches one of four approved indications (advanced prostate cancer with high recurrence risk, pre/perimenopausal ER/PR+ breast cancer, endometriosis, or endometrial ablation preoperative use).
04Confirm dosage authorization: require 3.6 mg for endometriosis and endometrial thinning; all dosages acceptable for cancer indications.
05Verify exclusions are documented: check for concomitant LHRH agents, pediatric status (<18 years), disease progression in breast cancer cases, and abnormal vaginal bleeding of unknown etiology.
06Update encounter forms and prior auth request templates to include these clinical checkpoints.
07Communicate to providers that claims lacking proper prior authorization or failing to meet clinical criteria will be denied.
08Configure authorization duration settings: initial and renewal at plan year duration for prostate/breast cancer; 6-month authorization for endometriosis; 2-month authorization for endometrial thinning.
09Reference www.humana.com/PAL for medical claim code requirements.
10Applies to Medicare Advantage, Traditional Medicare, and Medicaid (FL, KY, SC, VA) members only.
Codes mentioned
J9202
Original notice
Zoladex (goserelin) (Revised)
mcp.humana.com · Always check the source before changing claims.
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