Synvisc-One® and SYNVISC® are covered by the majority of 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.
Sanofi Patient Connection can help you understand coverage and coding guidelines for Synvisc-One and SYNVISC under a patient's commercial insurance.
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 eliminating 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.
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.