Download HYALURONIC ACID PRODUCTS Synvisc, Synvisc

Premier Health Plan
Pharmacy Services
Phone: 866-822-2714
Fax: 855-862-6518
HYALURONIC ACID PRODUCTS
Prior Authorization Form
Synvisc, Synvisc-One, Euflexxa
□ Standard Request (72 hours)
□ Expedited Request (24 hours)
If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life,
health, or ability to regain maximum function, you can request an expedited decision. For expedited requests
you will receive a decision within 24 hours. You cannot request an expedited coverage determination if you
are requesting reimbursement for a drug you already received.
Demographics
Patient Information
Prescriber Information
Patient Name:
Prescriber Name:
DOB:
Age:
NPI#:
Health Plan ID#:
Pharmacy Name:
Pharmacy Phone:
Drug Requested:
Strength:
Specialty:
Phone:
Fax:
Office Contact:
Direct Phone # or Ext:
Medication Information
New medication
Continuation of therapy
Start Date:
Directions:
Quantity Dispensed:
If this is continuation of therapy, please provide CHART DOCUMENTATION
indicating the member showed improvement while on therapy.
Billing Information
Billed by PHARMACY delivered to the
member or provider for administration.
(Must be billed under Medicare Part B)
Billed under MEDICAL
JCODE:____________
ICD-9 Code:_________
Place of Administration:
Physician’s Office
Hospital/Clinic
**J-Code block: Unable to buy and bill at POS-11 Physician Office**
Clinical Information
Diagnosis:___________________________________________ Date Diagnosed:_______________________
Does the member have osteoarthritis of the knee?
Yes
Please indicate knee being treated:
Right Knee
Left Knee
Both Knees
Has the member tried and failed a physician directed exercise or physical therapy program?
Yes
Has the member tried and failed Acetaminophen for at least 3 months?
Yes
Has the member tried and failed NSAIDs for at least 3 months?
Yes
Has the member tried and failed an Intra-articular corticosteroid injection for at least 3 months?
Yes
Does the member have an active joint infection?
Yes
No
No
No
No
No
No
Continuation of Therapy: All prior authorization renewals are reviewed to determine the Medical Necessity for continuation of
therapy. Authorization may be extended based upon chart documentation of significant improvement in pain and functional capacity.
Please provide any additional information which should be considered in the space below:
premierhealthplan.org/medicare
Revised: 12/2014
The information contained in this document is confidential. The information is only intended for the use of the individual or entity named above. If you are
not the intended recipient of this information, you are hereby notified that any disclosure, copying, or distribution of this information is strictly prohibited.
If you have received this message in error please immediately notify the sender by telephone listed above to arrange for its return.