Payer PolicyActive
Triamcinolone Acetonide Extended-Release Injectable Suspension (Zilretta™ )
EVICORE-MEDICAL_DRUG-38C530F3
EviCore by Evernorth
Effective: December 1, 2022
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Zilretta is covered only for the FDA‑approved indication—a single 32 mg intra‑articular injection for knee osteoarthritis—off‑label uses and prior receipt of Zilretta are excluded. Approval requires radiologic confirmation of knee osteoarthritis, documentation that the patient has not previously received Zilretta, evidence of inadequate response to a prior intra‑articular corticosteroid injection, and supporting records (radiology report, medication/treatment history).
Coverage Criteria Preview
Key requirements from the full policy
"FDA-approved indication: Zilretta is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee."
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