Hyaluronic derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz)
Indications for Prior Authorization
- Osteoarthritis of the knee
Patients must meet all the following criteria for the indication above (chart note documentation required)
- X-ray or MRI confirmation of osteoarthritis of the knee(s) or Grade 3 or 4 chondromalacia.
- Failure of analgesics such as acetaminophen in doses up to three grams a day or topical analgesics unless contraindicated or experiencing side effects
- Failure of trial of 2 prescription strength non-steroidal anti-inflammatory drugs (NSAID) over a minimum of 1-2 weeks, unless contraindicated, or experiencing intolerable side effects. NSAID trial can include steroid injection.
- Patient has been treated through a trial of physical therapy prior to requesting viscosupplementation
- Patients must not have had knee surgery in the past three months.
- Patient does not have "bone-on-bone" disease.
Repeat Course of Therapy
- Documentation of a positive response to the most recent course of therapy, including at least 3 months of clinical improvement supported by pain relief and/or increased functional capacity.
- Six months has elapsed since the administration of the previous course of viscosupplementation
The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee.
- Use in joints other than the knee
- Grade 1 or 2 chondromalacia
- Patient has "bone-on-bone disease"
- Any indication not listed above as covered
Drug Dose Regimen Authorization Limit
- Euflexxa 2 ml once weekly for 3 weeks 3 weeks
- Hyalgan 2 ml once weekly for 3-5 weeks 3-5 weeks
- Orthovisc 2 ml once weekly for 3-4 weeks 3-4 weeks
- Synvisc 2 ml once weekly for 3 weeks 3 weeks
- Supartz 2.5 ml once weekly for 5 weeks 5 weeks
Western Health Advantage Pharmacy and Therapeutics Committee
Approved: January 2013 | Revised: August 2016
Last review date: July 25, 2016