CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization for intra-articular hyaluronate (viscosupplementation)

This document is a prior authorization request form used by CVS Caremark for HMSA members requesting coverage of intra-articular hyaluronate (viscosupplement) injections for knee osteoarthritis and related indications. It governs what provider documentation and questions are required to obtain prior authorization and applies to prescribing clinicians and billing staff.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization for intra-articular hyaluronate (viscosupplementation)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form and fax supporting documentation to CVS Caremark at 1-866-237-5512.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20listed hyaluronate products

6 monthsconservative therapy trial

1-866-237-5512fax to submit form

1-808-254-4414prior auth questions

Coverage Criteria for Intra-articular Hyaluronate

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Clinical criteria for coverage

Coverage for intra-articular hyaluronate is assessed when the following grouped clinical criteria are met as indicated on the form.

Diagnosis requirement: Member has diagnosis of osteoarthritis of the knee (unilateral or bilateral) or other specified diagnosis documented on the form

Refer to question #1

Previous hyaluronate course: If member has received a previous course, details must be provided and response to prior course documented (questions #2, #13-16).

Includes whether pain relief was achieved and dates of prior and planned courses

Conservative therapy requirement: Member has tried and failed to respond adequately to a 6-month course of conservative therapy (exercise, physical therapy, weight-management counseling) and provider has documented the specific therapies tried (questions #3-5).6 months

Question #3 asks about 6 months of conservative therapy

Analgesic trial or intolerance: Member has tried and failed treatment with an oral/topical NSAID and with acetaminophen or tramadol, OR has documented contraindication or intolerance to these agents as described on the form (questions #6-12).

Specific NSAIDs are listed in question #7; intolerance details documented in questions #8-12

Timing between courses: For repeat courses, the next planned start date should be at least 6 months after the date of the last injection of the previous completed treatment course (questions #15-16).>= 6 months between courses

Question #16

Product selection and exceptions

Product requested: Provider must indicate the specific hyaluronate product requested from the listed set (Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Hymovis One, Monovisc, Orthovisc, Supartz FX, Synojoynt, Synvisc, Synvisc One, Triluron, Trivisc, Visco-3, or other specified).

Question A and question 17 list products

Preferred product check: Form asks whether the patient's treatment can be switched to a preferred product (Euflexxa, Synvisc, Synvisc One); if provider indicates intolerance to preferred products, supporting chart notes documenting intolerable adverse events must be attached.

Question B and D; action required to attach chart notes for intolerance to Synvisc or Synvisc One

The prior authorization form implements a preferred-product requirement: the plan’s preferred hyaluronate products are Euflexxa, Synvisc, and Synvisc One. Providers are asked whether the patient’s treatment can be switched to one of these preferred products; if the provider selects a preferred option, the form directs them to continue with the clinical criteria questions. If the provider indicates the patient cannot switch, the form proceeds to document reasons and supporting information (for example, intolerable adverse events to preferred products) that justify use of a non-preferred hyaluronate. The form lists the specific products requested so the reviewer can confirm whether the requested agent is preferred or non-preferred and whether adequate justification is provided for an exception.

Initial Therapy Coverage Requirements

Initial Therapy Criteria

Initial therapy coverage criteria

Diagnosis: Documented diagnosis of knee osteoarthritis or other indicated knee diagnosis as recorded on the form (question #1).

Question #1

Conservative therapy trial: Member has tried and failed to respond adequately to 6 months of conservative therapy (noninvasive management such as exercise program, strength training, physical therapy, and/or weight-management counseling) and provider documents specific therapies tried (questions #3-5).6 months

Question #3 and definitions

Analgesic trial or intolerance: Member either failed treatment with an oral/topical NSAID and failed acetaminophen or tramadol, OR has documented contraindication or intolerance to these agents allowing omission of those trials (questions #6-12).

Question #7 lists specific NSAIDs; questions #8-12 capture contraindications/intolerance

Continuation and Repeat Course Criteria

Continuation / repeat course criteria

Rules for continuation or repeat courses

Continuation if mid-course: If the patient is in the middle of a treatment course and requires additional injections to complete the current course, provider must indicate dates and affected joints and specify number of injections per product per course as listed on the form.

Question C and product-specific injection counts

Interval requirement for new course: Next planned course start date must be at least 6 months after the date of the last injection of the previous completed treatment course.>= 6 months

Questions #15-16

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed hyaluronate products and must be submitted to CVS Caremark using the HMSACOM Prior Authorization Request form. Fax the completed form to CVS Caremark toll‑free at 1-866-237-5512. For questions about prior authorization determinations, call CVS Caremark at 1-808-254-4414.

Fax: 1-866-237-5512
Questions about prior auth: 1-808-254-4414
Specialty Customer Care (CaremarkConnect): 1-800-237-2767

Note

Preferred‑product switch and intolerance documentation

The form asks whether the patient can be switched to a preferred product (Euflexxa, Synvisc, or Synvisc One). If a switch is possible, indicate the preferred product on the form and skip to the clinical criteria. If the member has documented intolerance to the preferred products, document the adverse events and attach supporting chart notes.

Preferred products: Euflexxa, Synvisc, Synvisc One
If switch = Yes, select product and skip to clinical criteria
If intolerance claimed, attach chart notes documenting adverse events

Documentation Required

Submission and supporting documentation

Submit the completed HMSACOM prior authorization form by fax. The prescriber must attest that the information is accurate and that supporting documentation is available for review. Approvals may be subject to dosing limits consistent with FDA labeling and evidence‑based guidance.

Fax submission required: 1-866-237-5512
Prescriber attestation and signature required on form
Approvals may be subject to dosing limits per FDA labeling/compendia

Denial Risk

Documentation responsiveness — risk of denial or delay

Provide an accurate diagnosis and include supporting documentation (chart notes, dates of prior injections, affected joint, and documentation of adverse events when claiming intolerance). Failure to provide complete and accurate clinical information and attachments may result in delayed review or denial of the request.

Document dates of prior injections and specific affected joint(s) when applicable
Attach chart notes when claiming intolerance to preferred products
Incomplete or inaccurate documentation may lead to denial or delay

Step	Requirement
1	Provider must indicate on the form whether the patient’s treatment can be switched to a preferred hyaluronate product (Euflexxa, Synvisc, or Synvisc One).
2	If provider selects a preferred product (Euflexxa, Synvisc, or Synvisc One), the form directs to skip to the clinical criteria questions for authorization processing.
3	If provider indicates the treatment cannot be switched to a preferred product, the form continues to Question C and requires additional information (e.g., whether patient is mid-course).

Quantity Limits by Product

Gelsyn-3

Gelsyn-3 dosing per course3 injections (2 mL each; 6 mL total) per treatment course.

GenVisc 850

GenVisc 850 dosing per course3 to 5 injections (2.5 mL each; 12.5 mL total) per treatment course.

Hyalgan

Hyalgan dosing per course3 to 5 injections (2 mL each; 10 mL total) per treatment course.

Hymovis

Hymovis dosing per course2 injections (3 mL each; 6 mL total) per treatment course.

Orthovisc

Orthovisc dosing per course3 or 4 injections (2 mL each; 8 mL total) per treatment course.

Supartz FX

Supartz FX dosing per course3 to 5 injections (2.5 mL each; 12.5 mL total) per treatment course.

Triluron

Triluron dosing per course3 injections (2 mL each; 6 mL total) per treatment course.

Trivisc

Trivisc dosing per course3 injections (2.5 mL each; 7.5 mL total) per treatment course.

Visco-3

Visco-3 dosing per course3 injections (2.5 mL each; 7.5 mL total) per treatment course.

Background

Intra-articular hyaluronate injections (viscosupplementation) are used for symptoms of knee osteoarthritis and the HMSA/CVS Caremark prior authorization form focuses on prior exposure and product selection. The form requires the prescriber to identify the specific hyaluronate product requested from a checklist (examples include Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synvisc, Synvisc One, Triluron, Trivisc, Visco-3, and others), and to indicate whether the patient can be switched to a preferred product (Euflexxa, Synvisc, Synvisc One), or whether the patient is mid-course and requires completion of a current treatment course. The form also documents the number of injections per treatment course by product to guide quantity and authorization decisions (for example, Gelsyn-3: 3 injections [2 mL each; 6 mL total]; Hymovis: 2 injections [3 mL each; 6 mL total]; GenVisc 850 and Supartz FX: 3–5 injections [2.5 mL each; 12.5 mL total]).

OpenPayer

Prior authorization for intra-articular hyaluronate (viscosupplementation)

Coverage Criteria for Intra-articular Hyaluronate

Initial Therapy Coverage Requirements

Continuation and Repeat Course Criteria

Provider Actions and Submission Requirements

Timing and Interval Coding Notes

Step Therapy / Preferred Product Questions

Quantity Limits by Product

Dispensing and Administration Site

Background

Definitions