Anthem Blue Cross (HMO, PPO, EPO)
Synvisc (hylan g-f 20)
Drugs for Muscles, Ligaments, Tendons, and Bones : Drugs for Muscles, Ligaments, Tendons, and Bones
  • Osteoarthritis: OA of the Knee:
    Duration: 1 year(s)
    Documented Diagnosis: No
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Elapsed Duration Since Previous Course of Therapy: N/A

  • PA Applies
  • Step Therapy: Osteoarthritis: OA of the Knee:
    ST Multiple Generics

  • Quantity Limit: 6 syringes per 28 day(s).

  • For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on drug coverage click  HERE;
  • Prior Authorization: Osteoarthritis: OA of the Knee:
    Duration: 1 year(s)

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