For U.S. Healthcare Professionals Only
Prescribing Information
Important Safety Information  |   Prescribing Information For U.S. Healthcare Professionals Only

Important Safety Information: SYNVISC and Synvisc-One are contraindicated in patients with known hypersensitivity to hyaluronan products or patients with infections in or around the target knee. Hypersensitivity reactions including anaphylactic reaction, anaphylactoid reaction, anaphylactic shock and angioedema have been reported for both SYNVISC and Synvisc-One. View More

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Specialty Pharmacy

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.

Find state by state reimbursement coverage information here.

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.

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

Accredo Order Form (PDF)

ACRO Order Form (PDF)

Aetna SPP Order Form (PDF)

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)

CVS Caremark Order Form (PDF)

Diplomat Order Form (PDF)

HomeCall RX Order 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)

OptumRX for United HealthCare (PDF)

Prescription Solutions Hyaluronate Enrollment Form (PDF)

Reliance Rx Order Form (PDF)

Triessant Orthopedic Prescription/Pharmacy Intake Form (PDF)

US Bioservices SPP 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)

Wellmark BCBS IA Treatment Request Form (PDF)*

Wellmark BCBS SD Treatment Request Form (PDF)*

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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Indication

SYNVISC® (hylan G-F 20) and Synvisc-One® (hylan G-F 20) are indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics, e.g., acetaminophen.

Important Safety Information

SYNVISC and Synvisc-One are contraindicated in patients with known hypersensitivity to hyaluronan products or patients with infections in or around the target knee. Hypersensitivity reactions including anaphylactic reaction, anaphylactoid reaction, anaphylactic shock and angioedema have been reported for both SYNVISC and Synvisc-One.

Do not concomitantly use disinfectants containing quaternary ammonium salts for skin preparation because hyaluronan can precipitate in their presence. Do not inject SYNVISC or Synvisc-One extraarticularly, into the synovial tissues, into the fat pad or joint capsule, or intravascularly.

The safety and efficacy of Synvisc-One in locations other than the knee, or for conditions other than osteoarthritis, or in combination with other intra-articular injectables, or in severely inflamed knee joints have not been established. Use caution when injecting SYNVISC or Synvisc-One in patients allergic to avian proteins, feathers, or egg products; who have evidence of lymphatic or venous stasis in the leg to be treated; or who have severe inflammation in the knee to be treated. Remove any synovial fluid or effusion before injecting SYNVISC or Synvisc-One. Strict adherence to aseptic technique must be followed to avoid joint infection. The safety and effectiveness of SYNVISC and Synvisc-One have not been established in children (≤21years old) or in pregnant or lactating women. Patients should be advised to avoid strenuous or prolonged weight-bearing activities for approximately 48 hours after treatment.

For SYNVISC

In clinical trials, the most commonly reported adverse events were transient pain, swelling, and or joint effusion in the injected knee. The following reported adverse events are among those that may occur in association with intra-articular injections, including Synvisc: arthralgia, joint stiffness, joint effusion, joint swelling, joint warmth, injection site pain, arthritis, arthropathy, and gait disturbance.

Full Prescribing Information for SYNVISC

For Synvisc-One

The most commonly reported adverse events were arthralgia, arthritis, arthropathy, injection site pain, and joint effusion. The following reported adverse events are among those that may occur in association with intra-articular injections, including Synvisc-One: arthralgia, joint stiffness, joint effusion, joint swelling, joint warmth, injection site pain, arthritis, arthropathy, and gait disturbance.

Full Prescribing Information for Synvisc-One