CurrentCareSourcePolicy N/A

PHARMACY POLICY STATEMENT Arkansas PASSE

Defines prior-authorization coverage criteria, dosing/quantity limits, and reauthorization requirements for Xipere (triamcinolone acetonide suprachoroidal injectable suspension) for treatment of macular edema associated with non-infectious uveitis under the medical benefit for Arkansas PASSE members.

Policy Summary

PayerCareSource

PolicyPHARMACY POLICY STATEMENT Arkansas PASSE

Policy CodePolicy N/A

Change TypeRevised (04/09/2025)Original 11/10/2021

Effective DateOct 1, 2025

Next Review Date

Key ActionPrior authorization is required for Xipere under the medical benefit; submit documentation meeting all initial authorization criteria including ophthalmologist involvement, diagnosis, baseline BCVA, and absence of ocular infection.

SourceLink

POLICY UPDATE CHANGES

Policy revised on 04/09/2025 (revision entry present).

New policy created 11/10/2021 for Xipere.

1Covered Indication (uveitic macular edema)

18+Minimum age (years)

4 mgDose per injection

2 vials/12wQuantity limit

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Coverage stance: covered_with_criteria. Subject: Xipere (triamcinolone) suprachoroidal injection for uveitic macular edema. Scope summary: Defines prior-authorization coverage criteria, dosing/quantity limits, and reauthorization requirements for Xipere for treatment of macular edema associated with non-infectious uveitis under the medical benefit. Effective date: 2025-10-01. Last review/revised: 2025-04-09.

Coverage thresholds

Age>= 18 years

Dosage interval4 mg (0.1 mL) every 12 weeks per eye

Quantity limit2 vials per 12 weeks

Initial Therapy Criteria — Uveitic Macular Edema

Initial Authorization – Uveitic Macular Edema

Covered when ALL of the following are met:

ALL of the following

Medication prescriber: Medication must be prescribed by or in consultation with an ophthalmologist
Age: Member is at least 18 years of age>= 18 years
Uveitis diagnosis: Member has a diagnosis of non-infectious uveitis (pan, anterior, intermediate, or posterior)
Baseline BCVA: Documentation of best corrected visual acuity (BCVA) at baseline
Macular edema diagnosis: Member has a diagnosis of macular edema associated with uveitis
Infection exclusion: Member does not have any active or suspected ocular or periocular infections
Dosage and quantity limit: Dosage allowed: 4 mg (0.1 mL) via suprachoroidal injection every 12 weeks (per eye)4 mg (0.1 mL) every 12 weeks (per eye)
Quantity limit: 2 vials per 12 weeks

Not Medically Necessary / Exclusions

Not covered when the condition is not listed in this policy:

Exclusion - off-label: Xipere is considered not medically necessary for treatment of conditions not listed in this document; refer to Off-Label policy for other indications

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required

Prior authorization is required for Xipere under the medical benefit; submit documentation meeting all initial authorization criteria including ophthalmologist involvement, diagnosis, baseline BCVA, and absence of ocular infection.

Documentation Required

Baseline documentation

Document best corrected visual acuity (BCVA) at baseline and include diagnosis of non-infectious uveitis with macular edema.

Documentation Required

Reauthorization documentation

For reauthorization, provide chart notes demonstrating improved or stabilized visual acuity and/or reduction from baseline in central subfield thickness (CST).

Billing Rule

Dosing and quantity limit

Limit dosing to 4 mg (0.1 mL) per suprachoroidal injection every 12 weeks per eye; quantity limit of 2 vials per 12 weeks.

Quantity limit: 2 vials per 12 weeks
Dosing interval: 4 mg (0.1 mL) every 12 weeks (per eye)

Background

Background: Xipere (triamcinolone acetonide suprachoroidal injectable suspension) is FDA-approved for macular edema associated with uveitis and is administered via a suprachoroidal injection to deliver medication to the choroid and retina. Suprachoroidal administration is a targeted technique that may lessen the risk of ocular adverse effects compared with intravitreal corticosteroids.

Definitions

BCVABest corrected visual acuity

CSTCentral subfield thickness

Policy Summary

PayerCareSource

PolicyPHARMACY POLICY STATEMENT Arkansas PASSE

Policy CodePolicy N/A

Change TypeRevised (04/09/2025)Original 11/10/2021

Effective DateOct 1, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

PHARMACY POLICY STATEMENT Arkansas PASSE

Coverage Summary

Initial Therapy Criteria — Uveitic Macular Edema

Continuation / Reauthorization Criteria

Not Medically Necessary / Exclusions

Applicable Codes & Benefit Status

Provider Actions & Billing Rules

Clinical Evidence & Rationale

Background

Revision History

Benefit Type	Medical
Prior Authorization	Prior Authorization Required