Intra-articular Hyaluronan Injections Step Therapy – Medicare Part B

Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Supartz FX, Triluron, TriVisc, or Visco-3 will be approved when ALL of the following are met:

    1. The requested medication is being used for ONE of the following:

        A. An FDA approved indication

OR

        B. An indication in CMS approved compendia

AND

    2. ONE of the following:

        A. The requested medication is the preferred medication

OR

        B. Information has been provided that indicates the patient has been treated with the request medication in the past 365 days

OR

        C. There is documentation that the patient has had an ineffective treatment response to the active ingredient(s) of ALL preferred medication(s)

OR

        D. The patient has a documented intolerance, hypersensitivity, or FDA labeled contraindication to the active ingredient(s) of ALL preferred medication(s)

OR

        E. The prescriber has submitted documentation indicating ALL preferred medication(s) are likely to be ineffective or are likely to cause an adverse reaction or other harm to the patient

Length of Approval: 6 months

Notes:

• Prerequisite medications may require prior review under Medicare Part D or Medicare Part B. Medicare Part D prerequisites will not be required for Medical Only members.
• Length of approval may be shorter due to provider network participation status.
• Coverage of one Medicare Part B Step Therapy medication could equate to multiple medication authorizations when they share the same Medicare Part B Step Therapy criteria.
• LCD/NCD criteria review completed, if applicable, in addition to the Plan’s Medicare Part B Step Therapy criteria.
   

*Preferred medications may vary based upon indication