Publication Date: 

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina.

Effective November 1, 2021, the Clinical Criteria ING-CC-0005 will include a trial and inadequate response or intolerance to two preferred hyaluronan agents in the Part B medical step therapy precertification review. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as-is current procedure). Step therapy will not apply for members who are actively receiving non-preferred medications listed below.

Clinical Criteria are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.


Clinical Criteria Preferred drug(s) Nonpreferred drug(s)

Euflexxa (J7323) 

Supartz FX (J7321)

Durolane (J7318)

Gelsyn-3 (J7328)

Including but not limited to:

  • Gel-One (J7326)
  • GenVisc 850 (J7320)
  • Hymovis (J7322)
  • Monovisc (J7327)
  • Orthovisc (J7324)
  • Synvisc/Synvisc One (J7325)
  • TriVisc (J7329)
  • Hyalgan/Visco-3 (J7321)
  • Triluron (J7332)
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is an independent licensee of the Blue Cross and Blue Shield Association.
BNCCARE-0190-21 August 2021 519447MUPENMUB