Anthem Blue Cross (HMO, PPO, EPO)
Monovisc (hyaluronate sodium, stabilized)
Drugs for Muscles, Ligaments, Tendons, and Bones : Drugs for Muscles, Ligaments, Tendons, and Bones

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

  • 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

  • Prior Authorization: Osteoarthritis: OA of the Knee:
    Duration: 1 year(s)

  • Quantity Limit: 2 syringes per 28 day(s).
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