CurrentCareSourcePolicy N/A

Yutiq (fluocinolone acetonide) intravitreal implant — Prior authorization coverage criteria

Prior authorization policy for coverage of Yutiq (0.18 mg fluocinolone acetonide intravitreal implant) for treatment of chronic non‑infectious uveitis affecting the posterior segment; applies to medical benefit pharmacy requests in CareSource (Arkansas PASSE) membership.

Policy Summary

PayerCareSource

PolicyYutiq (fluocinolone acetonide) intravitreal implant — Prior authorization coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateApr 9, 2025

Key ActionSubmit prior authorization with documentation that patient is ≥18, has chronic non-infectious posterior uveitis, failed ≥1 systemic therapy for ≥3 months, and no ocular infection.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0.18 mgimplant strength

36 monthsduration of effect

1 per eyelimit

≥18 yrsmin age

3 monthsapproval duration

Coverage Criteria

Initial Therapy

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

Initial authorization criteria: 1) Medication prescribed by or in consultation with an ophthalmologist; 2) Member is at least 18 years of age; 3) Diagnosis of chronic (1 year or more) non-infectious uveitis affecting the posterior segment of the eye; 4) Member has tried and failed at least one prior systemic therapy (for at least 3 months) (examples include systemic corticosteroid such as prednisone or tacrolimus); 5) No active or suspected infections in or around the eye; 6) Dosage/quantity limit: one implant (0.18 mg) per eye with a limit of 2 implants (one per eye) per 36 months.

If all requirements are met, approve for 3 months.

Reauthorization

Covered when ALL of the following are met for reauthorization:

Reauthorization criteria: 1) At least 36 months have elapsed since prior treatment of the same eye; 2) Chart notes document improved or stabilized visual acuity following treatment and/or an improved vitreous haze score; 3) Member has recurrent symptoms.

Policy Summary

PayerCareSource

PolicyYutiq (fluocinolone acetonide) intravitreal implant — Prior authorization coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateApr 9, 2025

Key ActionSubmit prior authorization with documentation that patient is ≥18, has chronic non-infectious posterior uveitis, failed ≥1 systemic therapy for ≥3 months, and no ocular infection.

SourceLink

On This Page

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If all requirements are met, approve for an additional 3 months.

CareSource considers Yutiq (fluocinolone acetonide intravitreal implant) not medically necessary for indications that are not specifically listed in this policy. Requests for off‑label use of Yutiq must be reviewed under the plan’s Off‑Label policy and require clinical justification and prior authorization.

Treatment of conditions other than chronic non‑infectious uveitis affecting the posterior segment is considered not medically necessary under this policy. Providers should not submit prior authorization requests for Yutiq for alternative ocular conditions unless an off‑label review is requested and approved.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Initial requests must be prescribed by or in consultation with an ophthalmologist and meet the policy's clinical criteria for chronic non-infectious uveitis affecting the posterior segment.

Applies to Yutiq (fluocinolone acetonide) intravitreal implant
One implant (0.18 mg) per eye; limit 2 implants (1 per eye) per 36 months

Denial Risk

Triggers for Denial

Denial may be triggered when specified exclusion or eligibility criteria are not met. Review these common triggers to avoid claim denial.

Age under 18 years
Diagnosis other than chronic (≥1 year) non-infectious uveitis affecting the posterior segment
Duration of disease less than 1 year
Active or suspected infection in or around the eye
Failure to document prior systemic therapy trial (see policy for required agents and durations)
Requests not prescribed by or in consultation with an ophthalmologist

Documentation Required

Required Documentation for Reauthorization

Documentation required for reauthorization: chart notes must demonstrate clinical benefit following prior treatment before additional dosing is approved.

Chart notes documenting improved or stabilized visual acuity following treatment and/or an improved vitreous haze score
Evidence that at least 36 months have elapsed since prior treatment of the same eye
Documentation of recurrent symptoms necessitating retreatment
Clinical notes confirming absence of active or suspected ocular infection

Background

Yutiq is a sustained‑release intravitreal implant that delivers fluocinolone acetonide for the treatment of chronic non‑infectious uveitis affecting the posterior segment. The implant provides prolonged local corticosteroid therapy intended to control intraocular inflammation and reduce recurrence of posterior segment uveitis. Use of Yutiq requires prior authorization and must meet the clinical criteria outlined in this policy, including documented benefit for reauthorization.

Definitions

Chronic non-infectious uveitis affecting the posterior segment — definition

DefinitionUveitis of the posterior segment that is noninfectious in etiology and has had a duration of one year or more (chronic = ≥1 year).

Affected anatomical areaPosterior segment of the eye (includes vitreous, retina, and choroid).

EtiologyNon-infectious inflammatory conditions (e.g., associated with systemic inflammatory diseases).

Clinical significanceMay require local intravitreal therapy when topical treatment is inadequate or when intermediate/posterior segments are involved.

Age considerationYutiq use and related policy apply to adults (≥18 years).