Summary
This is a revised Zoladex (goserelin) prior authorization policy effective January 1, 2017, with the most recent revision dated August 26, 2026. The policy covers four indications (prostate cancer, breast cancer, endometriosis, and endometrial thinning) across Medicare and four state Medicaid programs (Florida, Kentucky, South Carolina, Virginia) and establishes specific approval criteria, exclusions, and duration limits for each indication. Billing teams must ensure prior authorization is obtained before dispensing and verify member eligibility against indication-specific criteria and exclusions.
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What to do
Action · 7 steps
01Immediately implement the following.
02Billing team must verify all Zoladex claims require prior authorization before submission to Humana Medicare Advantage, Traditional Medicare, and Medicaid (FL, KY, SC, VA) plans.
03Create a claims screening checklist in billing software to verify: (a) member indication matches approved uses (prostate cancer, breast cancer, endometriosis, or endometrial thinning only); (b) member does NOT have any exclusions (concomitant LHRH agents, age <18, malignant progression for breast cancer, abnormal vaginal bleeding of unknown etiology); (c) for endometriosis and endometrial thinning, only 3.6 mg dosage is approved; (d) for breast cancer, member is pre- or perimenopausal with ER/PR+ status; (e) for prostate cancer, member has advanced disease or high recurrence risk.
04Providers must submit prior authorization requests with appropriate clinical documentation supporting medical necessity.
05Front desk/authorization team must track approval durations: prostate cancer and breast cancer = plan year or clinical review; endometriosis = 6 months; endometrial thinning = 2 months.
06Do NOT process or bill claims without documented prior authorization.
07Consequence: Claims submitted without prior authorization will be denied by Humana.
Original notice
Zoladex (goserelin) (Revised)
mcp.humana.com · Always check the source before changing claims.
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