CurrentCignaPolicy v060124

Zoladex (goserelin) prior authorization form

This document is a Cigna prior authorization request form for Zoladex (goserelin) implants used across multiple indications; it governs how providers submit requests and the clinical information required for review.

Policy Summary

PayerCigna

PolicyZoladex (goserelin) prior authorization form

Policy CodePolicy v060124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and fax the prior authorization form with required patient/provider identifiers, medication selection (3.6 mg or 10.8 mg), ICD-10, J-code, dose, frequency, and prescriber attestation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

855-840-1678fax number to submit completed form

800-882-4462urgent request phone number

Accredonationally preferred specialty pharmacy

Coverage Criteria

Initial Authorization Criteria

Policy Summary

PayerCigna

PolicyZoladex (goserelin) prior authorization form

Policy CodePolicy v060124

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Indication selection: Medication must be requested for one of the listed indications (abnormal uterine bleeding, breast cancer, endometriosis, gender-dysphoria/gender-incongruent care, peripheral precocious puberty, preservation of ovarian function/fertility during chemotherapy, prostate cancer, or other specified indication)

checkbox list on form

Form completion and identifiers: Required patient and provider identifiers (asterisked fields), dose, ICD-10, J-code, frequency, and prescriber attestation/signature must be provided

missing fields may delay or prevent response

Specialist consultation when indicated: For abnormal uterine bleeding or endometriosis, the medication should be prescribed by or in consultation with an obstetrician-gynecologist or women's health specialist; for preservation of ovarian function/fertility, prescribe by or in consultation with an OB-GYN or oncologist; for gender dysphoria/reassignment, prescribe by or in consultation with an endocrinologist or a physician who specializes in transgender care

checkbox confirmations present on form

Advanced disease query for oncology: For breast or prostate cancer indications, the form asks whether the patient has advanced disease to support clinical context

checkbox on form

The prior authorization form asks the provider to indicate where the medication will be obtained. Options on the form include selecting the nationally preferred specialty pharmacy (Accredo), the prescriber's office stock (to be billed on a medical claim), retail pharmacy, home health/home infusion vendor, or other specified source. The form captures facility and dispensing provider details (facility name, state, tax ID, address) when the medication will be dispensed or administered by a facility or doctor.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Zoladex (goserelin). Complete and fax the prior authorization form or submit online. Select the requested product: Zoladex 3.6 mg implant or Zoladex 10.8 mg 3-month implant and provide dose, frequency, J-code (if applicable), and ICD-10 diagnosis.

Medication requested: Zoladex 3.6 mg implant OR Zoladex 10.8 mg 3-month implant
Provide dose, frequency of administration, and J-code if applicable
Include ICD-10 code and specific diagnosis related to use

Documentation Required

Required Clinical & Administrative Information

Complete all required clinical and administrative fields to avoid processing delays. Provide the clinical indication and supporting clinical information: disease stage (if cancer), prior therapies, performance status, concurrent agents (names/doses/schedules), and answers to indication-specific questions on the form.

Diagnosis related to use (select from list or specify other)
Clinical information: disease stage, prior therapy, performance status, concurrent therapy details
If breast or prostate cancer — indicate whether disease is advanced
If abnormal uterine bleeding — indicate use as endometrial thinning agent prior to ablation

Denial Risk

Incomplete Mandatory Fields May Prevent Processing

All asterisked (*) fields are mandatory. Missing required identifiers will prevent processing or response by fax. Ensure the following are completed: Physician name, specialty, *DEA, *NPI or *TIN, office contact, office phone/fax, patient name, *Cigna ID, *Date of birth, patient and office addresses and phone numbers.

Mandatory identifiers: *DEA, *NPI or *TIN
Mandatory patient identifiers: *Cigna ID, *Date of Birth
Complete physician and office contact information (name, specialty, phone, fax, addresses)

Documentation Required

Specialist Involvement Required for Some Indications

Specialist involvement may be required for some indications. Document whether the medication is prescribed by or in consultation with the appropriate specialist as indicated on the form (e.g., obstetrician-gynecologist for abnormal uterine bleeding or endometriosis, oncologist for ovarian preservation during chemotherapy, endocrinologist or transgender care specialist for gender dysphoria/reassignment).

If abnormal uterine bleeding or endometriosis — Is the prescriber an OB-GYN or women's health specialist?
If preservation of ovarian function/fertility — Is the prescriber an OB-GYN or oncologist?
If gender dysphoria/reassignment — Is the prescriber an endocrinologist or transgender care specialist?

Initial Drug-specific Requirements

Initial drug-specific requirements

Initial authorization requires specifying formulation, dose, and administration details.

Formulation and dosing: Select Zoladex 3.6 mg implant (monthly) or Zoladex 10.8 mg 3-month implant and provide dose and frequency

checkboxes on form

Billing and acquisition information: Provide J-code and indicate where medication will be obtained (Accredo specialty pharmacy, prescriber's office stock [medical claim], retail pharmacy, home infusion/home health, or other)

form contains acquisition options and field for J-code

Clinical context and attestation: Include additional pertinent clinical information (disease stage, prior therapy, performance status, names/doses/administration schedule of concurrent agents) and prescriber attestation/signature

additional information and attestation fields on form

Site of Care / Dispensing Options

Billing Rule

Specify site of care / medication acquisition

Indicate where the medication will be obtained by selecting one option: Accredo Specialty Pharmacy, prescriber's office stock (medical claim), retail pharmacy, home health/home infusion vendor, or Other (specify).

Accredo Specialty Pharmacy (Cigna's nationally preferred specialty pharmacy)
Prescriber's office stock (billing on a medical claim)
Retail pharmacy, Home Health/Home Infusion vendor, or Other (specify)

Step Therapy / Specialist Confirmation

Indication	Specialist confirmation requested
Abnormal Uterine Bleeding	Yes — form asks whether medication is prescribed by or in consultation with an obstetrician-gynecologist or women's health specialist (checkbox)
Endometriosis	Yes — form asks whether medication is prescribed by or in consultation with an obstetrician-gynecologist or women's health specialist (checkbox)
Preservation of ovarian function/fertility during chemotherapy	Yes — form asks whether medication is prescribed by or in consultation with an obstetrician-gynecologist or oncologist (checkbox)
Gender-Dysphoric/Gender-Incongruent care	Yes — form requests consultation with an endocrinologist or clinician who specializes in transgender care (checkbox)
Breast cancer	No specialist-confirmation checkbox specified for routine breast cancer indication on the form; oncology-specific question limited to advanced disease (checkbox)
Prostate cancer	No specialist-confirmation checkbox specified for routine prostate cancer indication on the form; oncology-specific question limited to advanced disease (checkbox)
Peripheral Precocious Puberty	No specialist-confirmation checkbox specified on the form
Other (specified by provider)	Depends on indication provided — form includes free-text 'other' with no universal specialist checkbox

Medication Definitions

Medication name and formulation

Brand and generic nameZoladex (goserelin)

Formulations available on formZoladex 3.6 mg implant (monthly); Zoladex 10.8 mg 3-month implant

Administration routeSubcutaneous implant (as indicated by implant formulation selection on form)

Required prescription fields related to formulationDose and frequency must be provided on the form (Dose; Frequency of administration; J-code)

Clinical context promptForm asks oncology-specific question for breast or prostate cancer: whether patient has advanced disease

Background

Zoladex (goserelin) is a gonadotropin-releasing hormone (GnRH) agonist supplied as subcutaneous implants. The form provides checkboxes for the two available formulations: Zoladex 3.6 mg implant (monthly) and Zoladex 10.8 mg implant (3-month), and it requests the clinical indication (such as breast cancer, prostate cancer, endometriosis, abnormal uterine bleeding, precocious puberty, fertility preservation, or gender-affirming care) and related clinical details to support the request.

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