CurrentCareSourcePolicy N/A

Corticosteroids (Intraarticular) Zilretta Utilization Management Medical Policy

Defines prior authorization, coverage criteria, dosing limits, and documentation requirements for Zilretta (extended-release intraarticular triamcinolone) for osteoarthritis of the knee for CareSource members.

Policy Summary

PayerCareSource

PolicyCorticosteroids (Intraarticular) Zilretta Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateN/A

Next Review DateMay 7, 2025

Key ActionSubmit prior authorization documentation to request approval for one Zilretta injection per treated knee, including evidence of one prior intraarticular corticosteroid trial and radiologic confirmation of knee osteoarthritis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

32 mg/5 mLsingle-dose Zilretta formulation

one injectionapproved quantity per treated knee

30 daysauthorization duration

prior authauthorization requirement

prior steroidstep required

Recommended Authorization Criteria

FDA-Approved Indication

Covered when ALL of the following are met

FDA-Approved Indication: Diagnosis: Osteoarthritis pain of the knee confirmed by radiologic evidence.radiologic evidence (e.g., X-ray, MRI, CT, ultrasound)

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Prior intraarticular corticosteroid trial: Patient has tried one intraarticular corticosteroid injection in the knee to be treated (documentation required).one prior intraarticular corticosteroid injection

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No prior Zilretta retreatment: Patient is not receiving re-treatment of knee(s) previously treated with Zilretta.

Policy Summary

PayerCareSource

PolicyCorticosteroids (Intraarticular) Zilretta Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateN/A

Next Review DateMay 7, 2025

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization required — approves one injection per treated knee when criteria are met. Approval is for 30 days to allow administration of one dose per affected knee.

Approve one injection (32 mg/5 mL) administered by intraarticular injection per treated knee.
Approval duration: 30 days.

Prior Authorization

Prior Intraarticular Corticosteroid Trial

Patient must have tried one prior intraarticular corticosteroid injection in the knee to be treated. Documentation of the prior corticosteroid injection is required.

Examples of intraarticular corticosteroid injections: immediate-release triamcinolone acetonide; betamethasone sodium phosphate and betamethasone acetate; dexamethasone sodium phosphate; methylprednisolone acetate.

Documentation Required

Documentation required — chart notes, prescription claims, prescription receipts, or other supporting information may be requested to verify diagnosis, prior corticosteroid trial, and dosing.

Documentation may include: chart notes, prescription claims records, prescription receipts, imaging reports showing radiologic evidence of knee osteoarthritis.
Radiologic examples: X-ray, MRI, CT scan, ultrasound.

Denial Risk

Denial if Criteria Not Met

Requests that do not meet the Recommended Authorization Criteria may be denied.

Coverage not recommended for circumstances not listed in the Recommended Authorization Criteria.
Requests for doses outside the established dosing will be considered on a case-by-case basis and may be denied if criteria are not met.

Definitions and Examples

Zilretta — definition and single‑dose formulation details

ProductZilretta (triamcinolone acetonide) extended‑release intraarticular injection

Formulation and single‑dose strengthSingle intraarticular administration delivering 32 mg per 5 mL (32 mg/5 mL)

IndicationManagement of osteoarthritis pain of the knee

Dosing limitApprove one injection administered intraarticularly per treated knee

Limitation of useEfficacy and safety for repeat administration have not been demonstrated (no re‑treatment of knee(s) previously treated with Zilretta)

Immediate‑release intraarticular corticosteroids — examples

ExamplesImmediate‑release triamcinolone acetonide; betamethasone sodium phosphate and betamethasone acetate; dexamethasone sodium phosphate; methylprednisolone acetate

Use contextThese immediate‑release intraarticular corticosteroids are alternative injectables indicated for management of osteoarthritic conditions

Guideline noteGuidelines do not generally distinguish between short‑acting and extended‑release intraarticular corticosteroid products, though some guidance supports extended‑release for improved outcomes

OpenPayer

Corticosteroids (Intraarticular) Zilretta Utilization Management Medical Policy

Recommended Authorization Criteria

Coding

Provider Actions and Authorization Process

Background

Definitions and Examples