Hyaluronic acid derivatives

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

For further information, please see the Injectable Drugs page

Benefit: Medical

Notes:

  • 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

Code(s):

Hymovis, Hyalgan or Supartz: J7318, J7320, J7321, J7322, J7329, J7331

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)