CurrentCareSourcePolicy N/A
PHARMACY POLICY STATEMENT Akansas PASSE
Defines medical-benefit coverage criteria, prior authorization, quantity limits, allowed sites of service, and not medically necessary indications for Gelsyn-3 (J7328) as a preferred intra-articular hyaluronic acid product for osteoarthritis of the knee under CareSource.
Policy Summary
PayerCareSource
PolicyPHARMACY POLICY STATEMENT Akansas PASSE
Policy CodePolicy N/A
Change TypeHistorical edits to preferred status and clinical requirements
Effective DateJan 1, 2022
Next Review Date
Key ActionPrior authorization is required for Gelsyn-3 (J7328) under the medical benefit; document required diagnostic confirmation, failed therapies, and adhere to the 3-injection quantity limit and dosing.
SourceLink
POLICY UPDATE CHANGES
05/23/2017 - New policy created with age/BMI requirement changes, limits on additional courses, and trial of Supartz FX or Gel-One added.
08/04/2017 - Product status changed to preferred; trial requirement for Supartz FX or Gel-One removed.
1Covered Indication (knee OA)
5Not medically necessary indications listed
3Injection course (doses)
168Billing units per 2 mL injection