Commercial Payer Reimbursement
Synvisc-One® and SYNVISC® are covered by many commercial payers; however, you should be aware of patient-specific insurance benefits and plan restrictions.
Before treating a patient with Synvisc-One or SYNVISC, it is recommended that you conduct an insurance verification to understand patient-specific insurance coverage. This will help to assess if Synvisc-One and SYNVISC are covered, whether there is a specialty pharmacy option, whether there are setting-of-care restrictions, and what the patient's cost-sharing requirements, including deductibles, co-payments, co-insurance, and out-of-pocket maximums are.
MySynviscONE® may help you better understand coverage options and benefit verification for Synvisc-One and SYNVISC to help better assist your patients.
If your patient needs assistance in affording Synvisc-One or SYNVISC, Sanofi Patient Connection could potentially help. Click here to learn more.
Synvisc-One® and SYNVISC® commercial payer reimbursement
Under commercial payers, reimbursement for Synvisc-One®, SYNVISC® (hylan G-F 20) and the associated administration will vary, based on the contract established between the provider and payer.
Reimbursement for injectable products is generally based on average wholesale price (AWP), wholesale acquisition cost (WAC), or average sales price (ASP), plus or minus a contracted percentage.
In some instances under managed care, providers are capitated for all the costs of care, including injectable medications. They may receive a monthly per member per month (PMPM) payment and no additional reimbursement for specific services rendered. Alternatively, some commercial payers may require physicians to obtain Synvisc-One and SYNVISC through specialty pharmacies. In these cases, physicians neither bill nor receive payment for the product; rather, payers reimburse the specialty pharmacies directly for the product and physicians need only bill for their professional services.
Using a specialty pharmacy allows you to focus on patient care by potentially limiting the financial risk that carrying inventory for your commercial patients can pose.
Use the reimbursement-map to search for options each commercial payer has available.
Find Prior Authorization Form
In the hospital outpatient setting, commercial payers typically reimburse for Synvisc-One or SYNVISC, based on a contracted AWP-, WAC-, or ASP-based amount, plus or minus a certain percentage. Reimbursement for hospital administration services may be determined according to a prospectively set payment rate, similar to the OPPS APC system. Alternatively, payment may be based on case rate or other type of negotiated fee schedule.
Providers retain sole responsibility for determining reimbursement and insurance issues related to their patients and for ensuring the accuracy of their submission claims. Sanofi cannot be responsible for failure of a provider to obtain reimbursement.
Resources for Your Patients
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
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 extra-articularly, into the synovial tissues, into the fat pad or joint capsule, or intravascularly. Some cases of skin necrosis have been reported after intra-articular use of hyaluronic acid. Patients should be instructed to contact their treating physician if signs of skin disorder (such as change of color or open sores) appear.
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 (≤21 years 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.
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.
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.