Synvisc-One® and SYNVISC® may be obtained at no cost to your practice through a specialty pharmacy for your patients with commercial insurance. Specialty pharmacy providers (SPPs) dispense specialty pharmaceuticals and biologics, and offer benefits to your patients and your practice, including:
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.
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 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.
| Name of Drug: | Synvisc-One |
| Dosage: | 48mg |
| NDC number: | 58468-0090-03 |
| HCPCS Code: | J7325 |
Prior Authorization of Benefits Form (PAB) (v3.17.16)
California_Prior_Authorization_Form.pdf
Caremark Global_Prior_Authorization_Form.pdf
Colorado_State_PA_Request_Form.pdf
FL Blue Caremark Enrollement Form
Florida_Prior_Authorization_Form.pdf
General_UHC Prior Authorization Form.pdf
Hyaluronic Acid Derivatives Prior Authorization Request Form
Hyaluronan Injections of Knee PA Form
Hyaluronan Injections Request Form
Hyaluronan NTL and AP and AE PAB Fax Form.pdf
Knee Arthroscopy-Meniscal Tear/Osteoarthritis Authorization Form
Massachusetts_State_PA_Request_Form.pdf
Maxor Osteoarthritis Enrollment Form.pdf
Michigan_State_PA_Request_Form.pdf
Minnesota_State_PA_Request_Form_Commercial.pdf
Minnesota_State_PA_Request_Form_Exchange.pdf
Oregon_State_PA_Request_Form.pdf
Pharmacy Drug Authorization Request Form
Precertification & Prior Authorization Process Guidelines
Prescription & Enrollment Form_OsteoArthritis
Prior Authorization/Benefit Certification RequestForm
Prior Authorization Request Form
State of Vermont Urgent Request Uniform Medical Prior Authorization Form
Specialty_Pharmacy_Fax_Form.pdf
Synvisc and Synvisc One Precertification Fax Form
Texas_State_PA_Request_Form.pdf
USBioservices General Request Form.pdf
Viscosupplementation-Medication Precertification Request Form
*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)
OptumRX for United HealthCare (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)
Visit the MySynviscONE® section of the site for details and more.
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Learn about the different ordering options and how to get next-day delivery with your MySynviscONE® account.
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Share these tools to help patients get the most out of their treatment.
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