Synvisc-One® and SYNVISC® may be obtained at no cost to your practice through a specialty pharmacy for your commercial patients. Specialty pharmacy providers (SPPs) dispense specialty pharmaceuticals and biologics, and offer unique benefits to your patients and your practice, including:
- Billing and reimbursement support
- Product inventory and delivery
- Disease state information and clinical support services for your patients
Using an SPP allows you to focus on patient care by eliminating the financial risk that carrying inventory for your commercial patients can pose.
Specialty pharmacy forms
If you have patients whose insurers require them to order Synvisc-One and SYNVISC through specialty pharmacies, you may do so using one of these forms. If the form you are looking for is not listed below, please contact the patient's specific insurance company.
These forms are provided for your convenience and Sanofi Biosurgery makes no representation that they are the most current forms available. It is your sole responsibility to make sure that you check with your SPP to ensure you have the correct documentation.
PRIOR AUTHORIZATION FORMS
*Note: If you are submitting these forms for Synvisc-One, please write in the product name Synvisc-One on the form. You may also need to include the following information:
| Name of Drug: | Synvisc-One |
| Dosage: | 48mg |
| NDC number: | 58468-0090-03 |
| HCPCS Code: | J7325 |
Anthem IN OH KY MO WI Pre-Cert (hyaluronan PA) (PDF)
Anthem CT NH ME Pre-Cert (review request) (PDF)
Anthem CO NV Pre-Cert (hyaluronan PA) (PDF)
Anthem GA Pre-Cert (hyaluronan pre-determination) (PDF)*
Anthem VA Pre-Cert (drug health services review form) (PDF)
BCBS MA Prior Authorization Form (PDF)
BCBS MA SPP Prior Authorization Form (PDF)
ConnectiCare Prior Authorization Form (PDF)
HealthNet Northeast Prior Authorization Form (PDF)*
Humana Prior Authorization Form (PDF)
Humana 2009 Prior Authorization Pre Cert Form (PDF)*
Mass Health Drug Prior Authorization Request (PDF)
Neighborhood Health Plan DME Prior Authorization Request Form (PDF)
Presbyterian Specialty Drug Prior Authorization Request Form (PDF)
ORDER FORMS
*Note: If you are submitting these forms for Synvisc-One, please write in the product name Synvisc-One on the form. You may also need to include the following information:
| Name of Drug: | Synvisc-One |
| Dosage: | 48mg |
| NDC number: | 58468-0090-03 |
| HCPCS Code: | J7325 |
Anthem Blue Cross of CA Order Form (PDF)
BCBS Florida SPP Order Form (PDF)
BCBS Tennessee SPP Order Form (PDF)
BCBS Vermont Specialty Scripts SPP Order Form (PDF)
Capital Blue Cross of PA Hyaluronic Acid Derivatives Statement of Medical Necessity Form (PDF)*
Cigna Tel-Drug Specialty Pharmacy Joint Degeneration Fax Order Form (PDF)
Curascript Specialty Pharmacy HA Enrollment Form (PDF)
Horizon BCBS NJ Order Form (PDF)
Independence Blue Cross Injectable Drug Order Form (PDF)
Keystone Health Plan Central Hyaluronic Acid Derivatives Statement of Medical Necessity Form (PDF)*
Maxor Osteoarthritis Order Form (PDF)
McKesson Injectable Drug Request Form (PDF)
Medco Specialty Pharmacy Form (PDF)
Prescription Solutions Hyaluronate Enrollment Form (PDF)
Triessant Orthopedic Prescription/Pharmacy Intake Form (PDF)
Walgreens Medmark Orthopedic Prescription Pharmacy Intake Form (Ann Arbor) (PDF)
Walgreens Medmark Orthopedic Prescription Pharmacy Intake Form (Pittsburg) (PDF)
Walgreens Medmark Orthopedic Prescription Pharmacy Intake Form (Portland) (PDF)
Reimbursement map
Click on a state below to view a payer's specialty pharmacy requirement and access specific prior authorization and order forms.
This reimbursement material represents Sanofi's current understanding. Many topics covered in this guide are complex and all are subject to change beyond our control. Healthcare professionals are responsible for keeping current and complying with reimbursement policy and regulations. This information is not intended to be directive, nor does the use of the recommended codes guarantee reimbursement. Providers should select the codes that most accurately reflect the patient's medical condition, payer requirements, practice patterns and services rendered. Providers are responsible for the accuracy of any claims, invoices and related documentation submitted to payers.
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