Preferred Drugs - Hyaluronate knee injection products
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Defines preferred and non-preferred physician‑administered hyaluronate knee injection products for Health Choice Arizona and Health Choice Pathway and states that all listed products require prior authorization; applies to providers prescribing these intra‑articular knee injections.
No material clinical or coverage changes in this revision.
Coverage & Authorization
General authorization requirement
Coverage and authorization summary for listed hyaluronate knee injection products
Effective 4/1/2021
HCPCS Coding
Provider Requirements & Prior Authorization
Prior Authorization Required
Prior authorization is required for all listed hyaluronate knee injection products. Providers must obtain PA before administration or billing for these physician-administered drugs.
- All products listed require prior authorization
- Refer to Health Choice Prior Authorization (PA) Guidelines and PA Grids online
Non-Preferred Product Requests
A request for a non-preferred hyaluronate product requires supporting clinical documentation to justify medical necessity and why a preferred product is not appropriate.
Supporting Documentation and PA Guidance
When requesting prior authorization for non-preferred products, include relevant clinical records, prior treatment history, and rationale for product selection. Follow the payer's PA submission instructions and use the available PA Grids.
- Submit clinical records and prior treatment history
- Use PA Grids and follow submission instructions found on the Health Choice provider websites
PA Resources & Contacts
For PA resources and submission details, visit the Health Choice provider sites or contact your Network Service Provider Performance Representative for questions.
- HCA: https://www.healthchoiceaz.com/ -> Provider Tab -> PA Guidelines
- HCP: https://www.healthchoicepathway.com/ -> Provider Tab -> Provider Information
Background
This notice identifies physician‑administered hyaluronate intra‑articular knee injection products that have been designated as preferred or non‑preferred for Health Choice Arizona and Health Choice Pathway, effective 4/1/2021. It is administrative guidance to providers about payer product status and authorization requirements rather than clinical treatment guidelines. (See listed preferred and non‑preferred HCPCS codes.)
All products named in this notice require prior authorization. A request for a non‑preferred product will require supporting documentation to substantiate the medical necessity of using a non‑preferred product instead of a preferred alternative; providers should consult the payer’s Prior Authorization guidelines and PA grids for submission instructions and required documentation.
Definitions
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