Pharmacy Prior Authorization Criteria

Xipere (triamcinolone acetonide injectable suspension)

Indications for Prior Authorization

Xipere

• For diagnosis of Uveitis
  Indicated for the treatment of macular edema associated with uveitis.

Criteria

Xipere

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Uveitis

• Diagnosis of macular edema due to uveitis is confirmed by ONE of the following tests: [2, 3]
• Slit lamp exam
• Fundoscopic exam
• Fluorescein angiography
• Optical coherence tomography (OCT)
AND
• Patient is free of ocular and peri-ocular infections [1]
AND
• Patient does not have untreated intraocular pressure or uncontrolled glaucoma [1]
AND
• Trial and failure, contraindication or intolerance to at least ONE other corticosteroid (e.g., methylprednisolone, Ozurdex, prednisolone, prednisone, triamcinolone) [3]
AND
• Patient has not received any of the following sustained-release intravitreal corticosteroids: [4, 5]
• Dexamethasone (e.g., Ozurdex) within the past 6 months
• Fluocinolone acetonide within the past 30 months (e.g., Retisert) or 36 months ( e.g., Iluvien, Yutiq)
AND
• Prescribed by or in consultation with an ophthalmologist

Xipere

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Uveitis

• Patient demonstrates positive clinical response to therapy (e.g., improvement in Best Corrected Visual Acuity, stable vision)
AND
• Prescribed by or in consultation with an ophthalmologist

P & T Revisions

2024-01-04, 2023-11-16, 2023-01-03, 2022-01-12

References

1. Xipere Prescribing Information. Clearside Biomedical, Inc. Alpharetta, GA. February 2022.
2. National Organization for Rare Disorders. Posterior Uveitis. Available at https://rarediseases.org/rare-diseases/posterior-uveitis/. Acessed December 19, 2021
3. Koronis, S., Stavrakas, P., et al. Update in Treatment of Uveitic Macular Edema. Available at https://www.dovepress.com/update-in-treatment-of-uveitic-macular-edema-peer-reviewed-fulltext-article-DDDT. Accessed December 19, 2021.
4. Haghjou, N., Soheilian, M., et al. Sustained Release Intracoular Drug Delivery Devices for Treatment of Uveitis. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306122/. Accessed December 19, 2021.
5. Yutiq Prescribing Information. EyePoint Pharmaceuticals, Inc. Watertown, MA. October 2018.
6. UpToDate: Uveitis: Etiology, clinical manifestations, and diagnosis. Available at: https://www.uptodate.com/contents/uveitis-etiology-clinical-manifestations-and-diagnosis?search=macular%20edema%20asscoiated%20with%20uveitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed January 4, 2024.
7. Uptodate: Uveitis: Treatment. Available at: Uveitis: https://www.uptodate.com/contents/uveitis-treatment?search=macular%20edema%20asscoiated%20with%20uveitis&topicRef=5581&source=see_link. Accessed January 4, 2024.
8. Ozurdex Prescribing Information. Allergan USA, Inc. Madison, NJ. December 2022.
9. Iluvien Prescribing Information. Alimera Sciences, Inc. Alpharetta, GA. November 2016.
10. Retisert Prescribing Information. Bausch & Lomb Inc. Waterford, Ireland. May 2011.

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Revision History

• 2024-01-04: 2024 Annual Review
• 2023-11-16: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-01-03: 2023 Annual Review.
• 2022-01-12: 2022 New UM PA criteria

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