Goserelin Acetate (Zoladex®)

REQUIREMENTS: By November 1, 2026 (before effective date): 1. BILLING TEAM must: - Update billing system to require prior authorization for ALL Goserelin Acetate (Zoladex®) claims effective 12/1/26 - Program system to deny claims for 10.8 mg strength when diagnosis is NOT prostate cancer, breast cancer, or gender dysphoria (per EXCLUSIONS section) - Configure system to automatically flag claims requiring Androgen Receptor (AR) positive or Hormone Receptor (HR) positive status documentation per DOCUMENTATION requirements - Set up authorization limits by indication: Breast Cancer (12 months), Prostate Cancer (12 months), Ovarian Cancer (12 months), Endometriosis (6 months max), Endometrial Thinning (2 doses OR 6 months for chronic anovulatory bleeding), Gender Dysphoria (12 months), Ovarian Function Preservation (3 months), Acute Porphyria (12 months), Salivary Gland Tumor (12 months), Uterine Sarcoma (12 months) 2. PROVIDERS/CLINICAL STAFF must: - For Gender Dysphoria cases: Ensure prescribers are specialized providers (pediatric endocrinologist, family/internal medicine, OB-GYN) with mental health collaboration for patients under 18 - For Acute Porphyria cases: Ensure prescribers are experienced in porphyria management - Document all required criteria from COVERAGE CRITERIA section in patient chart before submitting authorization request - Collect and submit hormone receptor/androgen receptor test results with prior authorization request 3. FRONT DESK/AUTHORIZATION STAFF must: - Create prior authorization request templates for each indication listed in COVERAGE CRITERIA - Train staff on continuation of therapy requirements: For Breast/Prostate Cancer, Ovarian Cancer, Salivary Gland Tumor, Uterine Sarcoma—reauthorization requires clinical benefit documentation; for Gender Dysphoria—all original criteria must continue to be met; for Endometriosis/Endometrial Thinning—members must meet full COVERAGE CRITERIA requirements again - Implement checklist for Gender Dysphoria cases to confirm Tanner stage 2+, comorbidity control, contraindication education, fertility preservation counseling, informed decision-making capacity - Flag experimental/investigational uses (diagnoses NOT listed in FDA-Approved or Compendial Uses sections) for automatic denial Consequences of inaction: Claims will be denied without proper prior authorization, authorization limits will not be enforced (leading to overpayment), and coverage exclusions will not be applied (resulting in inappropriate payments for non-covered strength/indication combinations).