Zoladex (goserelin) (Revised)

By September 30, 2025: Billing and prior authorization teams must review and implement this Humana Medicaid Louisiana policy for Zoladex (goserelin). (1) Update billing system and PA workflow to require prior authorization for all four indications (prostate cancer, breast cancer, endometriosis, endometrial thinning). (2) Configure system to enforce exclusion rules: deny PA if member is <18 years old, has concomitant LHRH agents, has abnormal vaginal bleeding of unknown etiology, or (for breast cancer) has progressed malignancy. (3) For endometriosis and endometrial thinning, verify 3.6 mg dosage is authorized (10.8 mg will require clinical review). (4) Update encounter templates and PA request forms to capture required clinical criteria: prostate cancer (advanced diagnosis OR high recurrence risk), breast cancer (pre/perimenopausal status AND ER/PR+ hormone receptor status), endometriosis (diagnosis only), endometrial thinning (scheduled ablation procedure). (5) Set approval duration tracking: initial/renewal plan year for prostate/breast cancer; 6-month initial/renewal for endometriosis; 2-month initial/renewal for endometrial thinning. (6) Train billing staff that claims submitted without prior authorization or failing to meet documented criteria will be denied by Humana. This policy applies ONLY to Louisiana Medicaid members; verify plan type before applying. Reference www.humana.com/PAL for specific medical claim codes.