Payer PolicyActive
Fluocinolone Acetonide Intravitreal Implant (Retisert)
EVICORE-MEDICAL_DRUG-C5F57101
EviCore by Evernorth
Effective: December 1, 2018
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered only for the FDA‑approved indication of chronic non‑infectious uveitis affecting the posterior segment of the eye; active viral, bacterial, mycobacterial, or fungal ocular infection is excluded. Approval requires documentation of the diagnosis and absence of active ocular infection, dosing is limited to the 0.59 mg intravitreal implant (releases ≈0.6 μg/day tapering to ~0.3–0.4 μg/day) and is authorized for up to 30 months.
Coverage Criteria Preview
Key requirements from the full policy
"Diagnosis of chronic non-infectious uveitis affecting the posterior segment of the eye (required for approval)."
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