Zoladex (goserelin) (Revised)

By September 27, 2025: Billing team must update prior authorization workflows to reflect the revised Zoladex policy requirements. (1) Update billing software to flag all Zoladex (J9202) claims for prior authorization review. (2) Implement 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). (3) Confirm dosage authorization: require 3.6 mg for endometriosis and endometrial thinning; all dosages acceptable for cancer indications. (4) Verify 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. (5) Update encounter forms and prior auth request templates to include these clinical checkpoints. (6) Communicate to providers that claims lacking proper prior authorization or failing to meet clinical criteria will be denied. (7) Configure 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. Reference www.humana.com/PAL for medical claim code requirements. Applies to Medicare Advantage, Traditional Medicare, and Medicaid (FL, KY, SC, VA) members only.