CurrentHawaii Medical Service Association (HMSA)Policy N/A

Hyaluronate Products prior authorization

Prior authorization form and criteria for coverage of intra-articular hyaluronate products for osteoarthritis (primarily knee), used by providers submitting requests to CVS Caremark on behalf of HMSA members.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHyaluronate Products prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization to CVS Caremark (fax 1-866-237-5512) with required supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20listed hyaluronate product options on form

6 monthsrequired interval before repeat treatment course

3-5typical injections per treatment course

Prior authauthorization required via CVS Caremark

Coverage Criteria for Intra‑articular Hyaluronate

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Initial conditions

Prior hyaluronate therapy: Has the member received a previous course of intra-articular hyaluronate therapy for the knee?Yes/No
If Yes, branch to questions about response and timing
Conservative therapy: Member tried and failed to respond adequately to 6 months of conservative therapy (exercise/physical therapy/weight management and/or other non-drug therapy)6 months
Provider must list therapies tried
Analgesic trial: Member tried and failed or has contraindication/intolerance to NSAIDs and/or acetaminophen/tramadol as documented on form
Specific NSAIDs can be selected; intolerances require documentation
Timing for repeat course: If prior hyaluronate course completed, next planned start date should be at least 6 months after last injection>=6 months
If mid-course, provider documents number and dates of injections to complete current course

Attestation: Prescriber signature attests that documentation supporting the information is available for review

Form includes signature and date fields

Product regimen details

Product-specific treatment course details required:

Product selection and regimen: Requested hyaluronate product must be indicated; form lists product-specific number of injections per course (examples: Gelsyn-3: 3 injections; GenVisc 850: 3–5 injections; Hyalgan: 3–5 injections; Hymovis: 2 injections; Orthovisc: 3–4 injections; Supartz FX: 3–5 injections; Triluron: 3 injections; Trivisc: 3 injections; Visco-3: 3 injections)

If mid-course, provide dates and affected joints; form captures product choice and whether preferred alternatives were considered

The prior authorization form requests whether the patient's treatment can be switched to plan‑preferred hyaluronate products (Euflexxa, Synvisc, Synvisc One). If the patient can be switched to one of these preferred products and the provider elects that option, the form directs the request to the preferred product pathway. Coverage for a requested non‑preferred hyaluronate product may be precluded unless the provider documents an appropriate justification (for example, intolerance or adverse event to the preferred products).

The form requires documentation of prior conservative therapy and trials of analgesics/NSAIDs (or documented contraindications or intolerances). Requests that do not document an adequate trial of conservative measures (typically a 6‑month period of therapies such as exercise, physical therapy, or weight management where appropriate) or that lack documentation of trial/failure or contraindication to NSAIDs/acetaminophen/tramadol may not meet medical necessity criteria and coverage may be limited.

Initial Therapy Requirements

Initial therapy

Initial authorization requires documentation of prior conservative measures and analgesic trials:

Initial authorization criteria: Diagnosis of knee osteoarthritis; trial of and inadequate response to conservative therapy (6 months) and trial/failure of NSAIDs (or documented contraindication/intolerance) and trial/failure of acetaminophen or tramadol (or documented contraindication/intolerance); provider documents specific therapies tried and dates

Form branches to allow cases where contraindications/intolerances obviate trials

Continuation / Repeat Therapy

Repeat/Continuation therapy

Continuation or repeat courses require documentation of prior course and timing:

Repeat course timing: If member had a previous completed course, provide date of last injection and next planned start date; next course should start >=6 months after last injection>=6 months

If unable to complete prior course due to adverse reaction, indicate and provide documentation; if mid-course, list dates and joints for remaining injections

Coding and Timing

Requested diagnosis codeICD-10

ICD-10

Form requests the ICD-10 code for the diagnosis (field provided)

inv-06: Minimum interval between treatment courses

Minimum interval between treatment coursesNext planned start date must be at least 6 months after the date of the last injection of the previous completed treatment course

Documentation requiredProvide date of last injection of previous completed course and the start date of the next planned course on the form

If mid-courseIf the prior course was not completed due to adverse reaction, indicate and provide documentation instead of meeting the 6‑month interval requirement

Question	Response options / action
Is the patient's treatment able to be switched to a plan-preferred hyaluronate product?	Yes — Euflexxa (if selected, skip to clinical criteria)
	Yes — Synvisc (if selected, skip to clinical criteria)
	Yes — Synvisc One (if selected, skip to clinical criteria)
	No — continue to justify request for non‑preferred product (proceed to Question C and provide supporting documentation)

Quantity Limits and Product-Specific Regimens

inv-16: Product-specific number of injections per treatment course

Gelsyn-33 injections per treatment course (2 mL each; 6 mL total)

GenVisc 8503 to 5 injections per treatment course (2.5 mL each; 12.5 mL total)

Hyalgan3 to 5 injections per treatment course (2 mL each; 10 mL total)

Hymovis2 injections per treatment course (3 mL each; 6 mL total)

Orthovisc3 or 4 injections per treatment course (2 mL each; 8 mL total)

Supartz FX3 to 5 injections per treatment course (2.5 mL each; 12.5 mL total)

Visco-3 / Trivisc / TriluronVisco-3: 3 injections (2.5 mL each; 7.5 mL total); Trivisc: 3 injections (2.5 mL each; 7.5 mL total); Triluron: 3 injections (2 mL each; 6 mL total)

Provider Actions & Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required. Fax the completed HMSA/CVS Caremark prior authorization form to CVS Caremark toll-free at 1-866-237-5512. For questions regarding prior authorization determinations, contact CVS Caremark at 1-808-254-4414. For benefit eligibility, copay, or medication delivery questions, contact CaremarkConnect at 1-800-237-2767.

Fax: 1-866-237-5512
Prior auth questions: 1-808-254-4414
CaremarkConnect (eligibility/cost/delivery): 1-800-237-2767

Step Therapy

Preferred Product Substitution

Before approving a non-preferred hyaluronate product, the form asks whether the patient's treatment can be switched to a preferred product. The plan-designated preferred products are Euflexxa, Synvisc, and Synvisc One. If the prescriber indicates the patient can be switched to one of these, the review should follow the preferred-product pathway.

Preferred products: Euflexxa; Synvisc; Synvisc One
Form options to select: Yes — Euflexxa / Yes — Synvisc / Yes — Synvisc One / No

Documentation Required

Supporting Documentation Required

Attach supporting clinical documentation (e.g., chart notes) when asserting intolerance, adverse events, or contraindications to preferred products. The prescriber's signature on the form attests that the required documentation is included. Approvals may be subject to dosing limits per FDA labeling and evidence-based guidelines.

Include chart notes documenting intolerance or adverse event to preferred product(s)
Prescriber signature attests documentation is provided
Approvals may be subject to dosing limits

Denial Risk

Submission Requirement / Denial Risk

Failure to submit the completed prior authorization form and all required supporting documentation to CVS Caremark may result in denial of coverage. Ensure the form and attachments are faxed to 1-866-237-5512; incomplete submissions may delay or deny benefit determination.

Incomplete or missing form/attachments may result in denial
Fax submissions to: 1-866-237-5512

Site of Care / Dispense & Administration Settings

Billing Rule

Document dispensing and administration site

Complete the site-of-care fields on the form indicating where the drug will be dispensed and where it will be administered; options on the form include office, outpatient hospital, ambulatory surgical, home, pharmacy, inpatient hospital, and other listed settings.

Dispensed at: Office, Outpatient Hospital, Ambulatory Surgical, Inpatient Hospital, Pharmacy, etc.
Administered at: Ambulatory surgical, Home, Inpatient Hospital, Office, Outpatient Hospital, Pharmacy.

Background

This prior authorization form is used to document the clinical indication and prior treatments for intra‑articular hyaluronate therapy, primarily for osteoarthritis of the knee. It captures the diagnosis, prior conservative and non‑drug therapies, prior hyaluronate courses and response, and product‑specific injection regimens (including product selection and the number of injections per treatment course). The form also asks whether the member is mid‑course and records dates and number of injections when applicable.