CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Zoladex (goserelin acetate) Medical Prior Authorization

Customize your policy alerts

Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

Get alerted when Policy GA-MED-P-366579 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

CareSource Georgia Medicaid coverage of Zoladex for premenopausal adults with dysfunctional uterine bleeding undergoing endometrial ablation or symptomatic, confirmed endometriosis; specified clinical criteria, documentation, and quantity limits apply, and reauthorization is not permitted.

Policy Summary

PayerCareSource Georgia

PolicyZoladex (goserelin acetate) Medical Prior Authorization

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial revision

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit Zoladex requests for medical prior authorization under the Georgia Medicaid benefit.

SourceLink

POLICY UPDATE CHANGES

The benefit was changed from pharmacy to medical prior authorization.

A quantity limit was added for dysfunctional uterine bleeding.

A quantity limit was added for endometriosis.

Endometriosis coverage now requires confirmation of diagnosis by imaging or laparoscopy.

Endometriosis requests now require an attestation that the member is not breastfeeding.

The prior 30-day NSAID trial requirement for endometriosis was removed.

Reauthorization requirements were simplified for both covered indications.

2Covered clinical indications

28 daysDysfunctional uterine bleeding approval

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Zoladex (goserelin acetate) Medical Prior Authorization

Customize your policy alerts

Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

Get alerted when Policy GA-MED-P-366579 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCareSource Georgia

PolicyZoladex (goserelin acetate) Medical Prior Authorization

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial revision

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit Zoladex requests for medical prior authorization under the Georgia Medicaid benefit.

SourceLink

POLICY UPDATE CHANGES

The benefit was changed from pharmacy to medical prior authorization.

A quantity limit was added for dysfunctional uterine bleeding.

A quantity limit was added for endometriosis.

Endometriosis coverage now requires confirmation of diagnosis by imaging or laparoscopy.

Endometriosis requests now require an attestation that the member is not breastfeeding.

The prior 30-day NSAID trial requirement for endometriosis was removed.

Reauthorization requirements were simplified for both covered indications.

2Covered clinical indications

28 daysDysfunctional uterine bleeding approval

Covered Indications and Limitations

Dysfunctional Uterine Bleeding — Initial Authorization Criteria

Covered for initial authorization when all of the following are met:

ALL of the following

Member is premenopausal and 18 years of age or older.
Medication is prescribed by or in consultation with a gynecologist.
Member is undergoing endometrial ablation for dysfunctional uterine bleeding.
Provider attests that the member is not pregnant or breastfeeding.
One or two 3.6 mg depots are administered, with each depot given four weeks apart before endometrial ablation.Maximum 2 syringes per 28 days

Endometriosis — Initial Authorization Criteria

Covered for initial authorization when all of the following are met:

ALL of the following

Member is premenopausal and 18 years of age or older.
Medication is prescribed by or in consultation with a gynecologist.
Member has a diagnosis of endometriosis confirmed by imaging or laparoscopy.
Member has documented painful symptoms associated with endometriosis, such as pelvic pain or dysmenorrhea.
Member has failed a 3-month trial of a hormonal contraceptive.

Reauthorization is not permitted for Zoladex.

Requests for conditions not listed in this policy are excluded from coverage under this policy and must be addressed through the applicable Off-Label policy.

CareSource considers Zoladex not medically necessary for the treatment of conditions not listed in this document.

Authorization, Documentation, and Submission Requirements

Prior Authorization

Medical Prior Authorization Required

Zoladex requires medical prior authorization under the CareSource Georgia Medicaid benefit before it may be covered.

Prior Authorization

Dysfunctional Uterine Bleeding Authorization

For dysfunctional uterine bleeding, initial authorization may be approved for 28 days when all indication-specific criteria are met. The allowed dose is one or two 3.6 mg depots, administered four weeks apart before endometrial ablation.

Quantity limit: 2 syringes per 28 days.

Prior Authorization

Endometriosis Authorization

For endometriosis, initial authorization may be approved for 6 months when all indication-specific criteria are met. The allowed dose is one 3.6 mg implant subcutaneously every 28 days.

Clinical Background

Zoladex (goserelin acetate) is a gonadotropin-releasing hormone agonist. The policy describes its use for pain relief and reduction of endometriotic lesions in endometriosis and as an endometrial-thinning agent before endometrial ablation for dysfunctional uterine bleeding. Coverage is limited to these two indications and the clinical circumstances specified in the policy.

Documentation Required

Dysfunctional Uterine Bleeding Documentation

For dysfunctional uterine bleeding, submit documentation establishing each required clinical fact before requesting authorization.

Member is premenopausal and 18 years of age or older.
Zoladex is prescribed by or in consultation with a gynecologist.
Member is undergoing endometrial ablation for dysfunctional uterine bleeding.
Provider attests that the member is not pregnant or breastfeeding.
Requested dosing complies with one or two 3.6 mg depots, four weeks apart, and the 2 syringes per 28 days quantity limit.

Documentation Required

Endometriosis Documentation

For endometriosis, submit complete clinical documentation supporting the diagnosis, symptoms, treatment history, and safety requirements.

Member is premenopausal and 18 years of age or older.
Zoladex is prescribed by or in consultation with a gynecologist.
Endometriosis is confirmed by imaging or laparoscopy.
Documentation describes painful symptoms associated with endometriosis, such as pelvic pain or dysmenorrhea.
Member failed a 3-month hormonal contraceptive trial.
Provider attests that the member is not pregnant or breastfeeding.
Requested dosing complies with one 3.6 mg implant every 28 days and the 1 syringe per 28 days quantity limit.