Medicare AdvantagePrior AuthMedium impact
Zilretta® (triamcinolone acetonide extended-release injectable suspension) (Revised)
Humana·FL, KY, SC · Orthopedics, Rheumatology, Pain Management·Pharmacy
Effective date
Jan 28, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Zilretta (triamcinolone acetonide extended-release) prior authorization policy effective January 28, 2026. Key changes include clarification that step therapy requirements (prior failure with two short-acting intra-articular steroids) do not apply to Florida Medicaid, and Medicare Part B continuation therapy within 365 days is exempted from step therapy. The policy maintains strict criteria: documented knee osteoarthritis, no prior Zilretta use in the same knee, and (except for Florida Medicaid) inadequate response to two different short-acting intra-articular steroids.
Action Required
By January 28, 2026: Billing and prior authorization teams must update internal workflows and PA submission protocols to reflect state-specific step therapy exemptions. Specifically: (1) For Florida Medicaid requests—REMOVE step therapy requirement for two prior short-acting intra-articular steroids; (2) For Medicare Part B requests—verify if the request is continuation therapy within past 365 days and EXEMPT from step therapy if applicable; (3) For Kentucky and South Carolina Medicaid—MAINTAIN step therapy requirement (two prior agents required). Update PA submission templates, staff training materials, and billing software decision trees to reflect these distinctions. Front desk and authorization staff must confirm member plan type and state before submitting Zilretta PA requests. Failure to apply correct step therapy rules will result in claim denials or unnecessary delays.