Hyaluronic acid derivatives

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Benefit: Medical


  • Treatment of osteoarthritis of the knee
  • ALL  formulations are NOT COVERED for fully funded or self-funded group plans or Medicaid as of January 1, 2017
  • Covered for Medicare without prior authorization


Hymovis, Hyalgan or Supartz: J7320, J7322, J7322

Euflexxa: J7323

Orthovisc: J7324; length of authorization, 3-5 injections

Synvisc or Synvisc One: J7325; length of authorization, 1-5 injections

Gel-One: J7326

Monovisc: J7327

Gel-Syn: J7328 (0.1mg)

GelVisc: Q9980 (1mg)