CurrentMass General Brigham Health PlanPolicy N/A

Zilretta (triamcinolone extended-release) — Coverage Criteria

Policy governing prior authorization and quantity/coverage limits for Zilretta (triamcinolone extended-release) when used for management of osteoarthritis knee pain for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyZilretta (triamcinolone extended-release) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis plus physician attestation of inadequate response or adverse reaction to two different intra‑articular corticosteroid injections (or contraindication to all others).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2required prior intra-articular corticosteroid trials

30 daysinitial approval duration

single doserepeat dose limitation

knee OAindication covered

Coverage Criteria for Zilretta (triamcinolone extended-release)

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Initial Therapy — Covered when ALL of the following are met and documentation is provided.

Covered when ALL of the following are met and documentation is provided:

Initial Authorization Criteria: Diagnosis of osteoarthritis pain of the knee; physician attestation of inadequate response or adverse reaction to TWO different intra-articular corticosteroid injection preparations OR documentation of contraindication to ALL other intra-articular corticosteroid injection preparations; appropriate dosing.

Documentation must be provided.

Limitations: Initial approvals will be granted for 1 month (30 days); Zilretta is not intended for repeat administration.

Repeat dosing of Zilretta is explicitly limited. Zilretta is not intended for repeat administration; initial approvals are for a single course only. Requests for additional administrations beyond the initial authorized dose may be denied unless documentation demonstrates exceptional clinical justification consistent with policy criteria.

Provider Action and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for Zilretta under the pharmacy benefit. Approval is granted only when all coverage criteria are met and complete supporting documentation is provided.

Pharmacy benefit prior authorization applies
Contact phone/fax per plan for submission

Documentation Required

Documentation Requirement — Trials of Intra-articular Corticosteroids

Approval requires documentation that the member has had a trial with, and experienced an inadequate response or an adverse reaction to, TWO different intra-articular corticosteroid injection preparations (or a documented contraindication to all other intra-articular corticosteroid injection preparations).

Document the two distinct corticosteroid preparations tried
If contraindication to all other preparations, document the reason

Documentation Required

Physician Attestation Required

Physician attestation is required confirming inadequate response or adverse reaction to two different intra-articular corticosteroid injection preparations (or a contraindication to all other preparations). Requests without this attestation will be denied or returned.

Attestation must be signed by the treating physician
Include dates and details of each trial and the nature of the inadequate response or adverse reaction

Denial Risk

Incomplete Requests — Denial or Return Risk

Incomplete requests — Requests lacking documentation of diagnosis (osteoarthritis pain of the knee), required physician attestation of trials or contraindications, or appropriate dosing information will be denied or returned for more information.

Missing diagnosis documentation
Missing physician attestation of two trials or contraindication
Missing dosing information or other required evidence

Initial Therapy Authorization Criteria

Initial Therapy — Authorization criteria

Authorization may be granted when the following documented criteria are met:

Documentation and trials: Diagnosis of osteoarthritis pain of the knee; physician attestation of inadequate response or adverse reaction to two different intra-articular corticosteroid injection preparations OR documentation of contraindication to all other intra-articular corticosteroid injection preparations; appropriate dosing.

Documentation must accompany the request.

Approval duration and repeat dosing: Initial approval granted for 30 days; product is not intended for repeat administration.

Step	Requirement
1	Document trial and inadequate response or adverse reaction to TWO different intra-articular corticosteroid injection preparations prior to approval, or documentation of contraindication to ALL other intra‑articular corticosteroid injection preparations.

Policy Summary

PayerMass General Brigham Health Plan

PolicyZilretta (triamcinolone extended-release) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review DateN/A

SourceLink

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Zilretta (triamcinolone extended-release) — Coverage Criteria

Coverage Criteria for Zilretta (triamcinolone extended-release)

Provider Action and Documentation Requirements

Initial Therapy Authorization Criteria

Step Therapy / Prior Treatment Requirements

Quantity Limits

Definitions

Background