CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Retisert Coverage for Chronic Noninfectious Posterior Uveitis

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Medical prior authorization and coverage requirements for the 0.59 mg Retisert intravitreal implant for CareSource Georgia Medicaid members with chronic noninfectious posterior uveitis.

Policy Summary

PayerCareSource Georgia

PolicyRetisert Coverage for Chronic Noninfectious Posterior Uveitis

Policy CodePolicy GA-MED-P-366579

Change TypeClinical criteria update

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit medical prior authorization documenting all coverage criteria, including a failed trial of Ozurdex, Yutiq, or Iluvien.

SourceLink

POLICY UPDATE CHANGES

Yutiq was added as an acceptable failed-trial option for initial Retisert authorization.

Iluvien was added as an acceptable step-therapy option for initial Retisert authorization.

≥12 yearsMinimum member age

≥1 yearChronic disease duration

3 monthsRequired prior therapy trial

1 implantQuantity per eye

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CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Retisert Coverage for Chronic Noninfectious Posterior Uveitis

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

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Medical prior authorization and coverage requirements for the 0.59 mg Retisert intravitreal implant for CareSource Georgia Medicaid members with chronic noninfectious posterior uveitis.

Policy Summary

PayerCareSource Georgia

PolicyRetisert Coverage for Chronic Noninfectious Posterior Uveitis

Policy CodePolicy GA-MED-P-366579

Change TypeClinical criteria update

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit medical prior authorization documenting all coverage criteria, including a failed trial of Ozurdex, Yutiq, or Iluvien.

SourceLink

POLICY UPDATE CHANGES

Yutiq was added as an acceptable failed-trial option for initial Retisert authorization.

Iluvien was added as an acceptable step-therapy option for initial Retisert authorization.

≥12 yearsMinimum member age

≥1 yearChronic disease duration

3 monthsRequired prior therapy trial

1 implantQuantity per eye

2 implants/30 monthsMaximum quantity

3 monthsApproval duration

Coverage Criteria

Initial Therapy

Initial authorization is covered when ALL of the following are met.

Initial authorization

Member and prescriber requirements: The member is at least 12 years of age, and the medication is prescribed by or in consultation with an ophthalmologist.Age ≥12 years
Diagnosis: The member has chronic noninfectious uveitis affecting the posterior segment of the eye.Chronic for ≥1 year
Prior anti-inflammatory therapy: The member has tried and failed at least one systemic corticosteroid or one non-biologic immunosuppressive medication for at least 3 months.Trial duration ≥3 months
Examples include prednisone, mycophenolate mofetil, methotrexate, cyclosporine, or tacrolimus.
Prior intravitreal implant therapy: The member has failed a trial of Ozurdex, Yutiq, or Iluvien.
At least one listed agent must have been tried and failed.
Safety requirement: The member does not have any active infections of the eye.No active ocular infection

Quantity and authorization limit: The requested quantity is no more than one 0.59 mg implant per eye and no more than two implants total, one per eye, per 30 months.1 implant/eye; maximum 2 implants per 30 months

Continuation Therapy

Reauthorization is covered when ALL of the following are met.

Reauthorization

Documented clinical response: Chart notes show improved or stabilized visual acuity following treatment and/or an improved vitreous haze score.Improved or stabilized visual acuity and/or improved vitreous haze score
Retreatment interval: At least 30 months have elapsed since the prior treatment of the same eye.≥30 months
Disease recurrence: The member has recurrent symptoms.Recurrent symptoms present

Active infection of the eye is an exclusion to initial authorization. The member must not have any active ocular infection when Retisert is requested.

Retisert is not medically necessary for the treatment of conditions or indications not listed in this policy. Other indications should be evaluated under the applicable Off-Label policy.

Quantity and Treatment Parameters

Minimum age

Minimum ageAt least 12 years

Applies toInitial authorization for Retisert

RequirementThe member must be at least 12 years of age

Chronic disease duration

Required duration1 year or more

ConditionChronic noninfectious uveitis affecting the posterior segment of the eye

Applies toInitial authorization

Authorization and Documentation Requirements

Prior Authorization

Medical Prior Authorization Required

Medical prior authorization is required for Retisert (fluocinolone acetonide). Initial requests should document the member’s age, prescribing ophthalmologist or ophthalmology consultation, chronic posterior-segment noninfectious uveitis, required prior treatment trials, and absence of active eye infection.

Member must be at least 12 years of age.
Medication must be prescribed by or in consultation with an ophthalmologist.
Document chronic noninfectious uveitis of at least 1 year affecting the posterior segment of the eye.
Document that the member does not have an active eye infection.

Billing Rule

Product and Policy Background

Retisert is a 0.59 mg fluocinolone acetonide intravitreal implant indicated for chronic noninfectious uveitis affecting the posterior segment of the eye. The implant delivers therapy within the eye and is used in the covered disease context established by this policy.

Clinical Definitions

Uveitis

DefinitionUveitis is inflammation of the uvea

Anatomic locationThe uvea is the middle layer of the eye

Disease classificationUveitis may be infectious or noninfectious

Chronic noninfectious posterior uveitis

DefinitionUveitis associated with inflammatory conditions and affecting the posterior segment of the eye

Inflammatory associationNoninfectious uveitis is often associated with inflammatory conditions such as rheumatoid arthritis

Chronicity requirement

Policy Summary

PayerCareSource Georgia

PolicyRetisert Coverage for Chronic Noninfectious Posterior Uveitis

Policy CodePolicy GA-MED-P-366579

Change TypeClinical criteria update

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit medical prior authorization documenting all coverage criteria, including a failed trial of Ozurdex, Yutiq, or Iluvien.

SourceLink

On This Page

Continuation quantity: Reauthorization applies to an additional 3-month approval period and remains subject to the policy quantity limit.Additional approval: 3 months

Required systemic or non-biologic immunosuppressive trial

Minimum trial durationAt least 3 months

Required therapyA systemic corticosteroid or non-biologic immunosuppressive medication

ExamplesPrednisone, mycophenolate mofetil, methotrexate, cyclosporine, or tacrolimus

Per-eye quantity

Allowed quantityOne 0.59 mg implant per eye

MedicationRetisert (fluocinolone acetonide) intravitreal implant

Quantity basisPer eye

Overall quantity limit

Maximum quantity2 implants per 30 months

Distribution1 implant per eye

LimitNo more than two implants total during a 30-month period

Same-eye retreatment interval

Required intervalAt least 30 months since prior treatment

Treatment siteThe same eye

Applies toReauthorization or retreatment

Initial Authorization Duration and Quantity

When all initial authorization criteria are met, Retisert is approved for 3 months. The allowed quantity is one 0.59 mg implant per eye, with a maximum of two implants—one per eye—in any 30-month period.

Initial approval duration: 3 months.
Quantity: one 0.59 mg implant per eye.
Maximum: two implants (one per eye) per 30 months.

Prior Authorization

Reauthorization Requires Continuation Criteria

Reauthorization requires documentation that all continuation criteria are met. If approved, treatment is authorized for an additional 3 months.

At least 30 months must have elapsed since treatment of the same eye.
The member must have recurrent symptoms.
Submit the required continuation clinical documentation.

Step Therapy

Required Prior Therapy Trials

Before initial authorization, the member must have tried and failed at least one qualifying systemic or non-biologic immunosuppressive therapy for at least 3 months, as well as a failed trial of an accepted intravitreal implant option.

Systemic corticosteroid, such as prednisone, for at least 3 months; or
Non-biologic immunosuppressive therapy, such as mycophenolate mofetil, methotrexate, cyclosporine, or tacrolimus, for at least 3 months.
Document a failed trial of Ozurdex, Yutiq, or Iluvien.

Documentation Required

Reauthorization Clinical Documentation

For reauthorization, chart notes must show treatment response or stabilization, including improved or stabilized visual acuity following treatment and/or an improved vitreous haze score.

Submit chart-note evidence of improved or stabilized visual acuity and/or improved vitreous haze.
Document recurrent symptoms and the required retreatment interval.

Denial Risk

Initial Criteria Not Met

Initial authorization may be denied when any required criterion is not met or cannot be documented. Unmet age, specialist, diagnosis, prior-therapy, infection, or quantity requirements create a denial risk.

Member is younger than 12 years of age.
No ophthalmologist prescription or consultation is documented.
Chronic posterior-segment noninfectious uveitis of at least 1 year is not established.
Required systemic or non-biologic therapy and implant trials were not failed or were not completed for the required duration.
Active eye infection is present.
Requested quantity exceeds the policy limit.

Denial Risk

Reauthorization Criteria Not Met

Continuation authorization may be denied when the required clinical response, recurrent symptoms, or retreatment interval is not documented. Requests are not eligible until at least 30 months have elapsed since treatment of the same eye.

Chart notes do not show improved or stabilized visual acuity and/or improved vitreous haze.
The member does not have recurrent symptoms.
Fewer than 30 months have elapsed since treatment of the same eye.

Denial Risk

Unlisted Indication

Retisert is not medically necessary for conditions or indications not listed in this policy. For another indication, refer the request for evaluation under the applicable Off-Label policy.

Do not submit Retisert under this policy for an unlisted indication.
Refer other-indication requests for review under the Off-Label policy.

Denial Risk

Quantity Limit Exceeded

Requests exceeding the allowed quantity may be denied. The policy permits one 0.59 mg implant per eye, with no more than two implants per 30 months—one for each eye.

Per-eye limit: one implant.
30-month limit: two implants total, one per eye.
Additional or excess quantity requires review and is not covered under the stated quantity limit.

The policy requires the condition to be chronic for 1 year or more and noninfectious