Medicare AdvantagePrior AuthMedium impact
Zusduri (mitomycin) (Revised)
Humana·KY, SC · Urology, Oncology·Medicaid
Effective date
Aug 27, 2025
We identified it
Sep 2, 2026
Summary
This is a new Humana prior authorization policy for Zusduri (mitomycin) intravesical treatment for recurrent low-grade intermediate-risk non-muscle invasive bladder cancer (LG-IR-NMIBC), effective August 27, 2025. Coverage requires documented recurrent disease, no prior Zusduri therapy, and absence of bladder perforation. Initial and renewal approval is limited to 6 months (maximum 6 doses per period).
Action Required
By August 27, 2025: Billing team must implement prior authorization requirements in billing system for Zusduri (mitomycin) claims for Medicare and Medicaid members in Kentucky and South Carolina. Update claim submission processes to verify: (1) member has diagnosis of LG-IR-NMIBC, (2) documented recurrent disease, (3) no prior Zusduri therapy, and (4) no bladder perforation. Configure system to limit approvals to 6 doses per 6-month period. Providers must submit prior authorization requests before dispensing. Train billing staff on new requirement. Update claim denial logic to reject claims missing required documentation or exceeding 6-dose limit. Claims submitted without prior authorization will be denied. Refer to Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for specific medical and procedural coding details.