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Effective April 1, 2015, injectable hyaluronate acid products to
treat osteoarthritis of the knee will no longer be available through the
AmeriHealth Direct Ship Injectables Program. The drugs that are included with
this change are Euflexxa™, Gel-One®,
Hyalgan®, Monovisc®, Orthovisc®,
Supartz®, Synvisc®, and Synvisc-One™.
These eight drugs will continue to be covered under the medical benefit for
members who meet the medical necessity criteria listed in the applicable
medical policy:
- Commercial: #11.14.07l: Intra-Articular Injection of Hyaluronan for
the Treatment of Osteoarthritis;
- Medicare Advantage: #MA11.023: Hyaluronan Acid Therapies for
Osteoarthritis of the Knee.
How this change affects providers
Providers who prescribe hyaluronate acid products will need to purchase
these drugs from the manufacturer or a specialty pharmacy vendor and stock them
in their office. In order to receive reimbursement for the cost of the
pharmaceutical, the provider will need to submit a claim to AmeriHealth.
Depending on the terms of the member's 2015 benefit contract, members may be
subject to additional cost-sharing amounts for these drugs. Therefore,
providers should discuss this change with their patients prior to April 1,
2015.
In January, letters were sent to physicians who prescribe and administer
hyaluronate acid products to notify them of this change and to provide more
information about the process for purchasing these drugs.
Clarification: As of January 1, 2015, precertification requirements
were removed for Orthovisc®, Synvisc®, and
Synvisc-One, our three preferred products. The other five drugs in this class
(Euflexxa™, Gel-One®, Hyalgan®,
Monovisc®, and Supartz®) still require
precertification from AmeriHealth. Providers who administer nonpreferred
hyaluronate acid products without precertification approval will not be
reimbursed. Providers who are currently ordering any hyaluronate acid
product through the Direct Ship Injectables Program must continue to obtain
authorization from AmeriHealth, regardless of whether the drug requires
precertification. As a reminder, March 31, 2015, is the last day that
hyaluronic acid products can be ordered through the AmeriHealth Direct Ship
Injectables Program.
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