Payer PolicyActive
Triamcinolone Acetonide Extended-Release Injectable Suspension (Zilretta)
EVICORE-MEDICAL_DRUG-26B562D1
EviCore by Evernorth
Effective: December 1, 2019
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered only for a single 32 mg intra‑articular injection of Zilretta for FDA‑approved knee osteoarthritis; non‑FDA uses, other joints, and prior receipt of Zilretta are excluded. Approval requires the patient be Zilretta‑naïve with documented knee OA, inadequate response/intolerance/contraindication to ≥2 of acetaminophen, NSAIDs, or tramadol, prior inadequate response to an intra‑articular corticosteroid, and meeting applicable safety/documentation requirements.
Coverage Criteria Preview
Key requirements from the full policy
"Zilretta is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee."
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