Synvisc, Synvisc-One, Supartz, Hyalgan, Euflexxa, Orthovisc Prior Authorization Form

Download a blank fillable Synvisc, Synvisc-One, Supartz, Hyalgan, Euflexxa, Orthovisc Prior Authorization Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Synvisc, Synvisc-One, Supartz, Hyalgan, Euflexxa, Orthovisc Prior Authorization Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Prior Authorization Form

Synvisc®, Synvisc-One

, Supartz®, Hyalgan®, Euflexxa®, Orthovisc®

ONLY COMPLETED REQUESTS WILL BE REVIEWED

Synvisc®

Supartz®

Hyalgan®

Euflexxa®

Orthovisc®

Synvisc-One

New Request

Refill Request (skip question 2 and 3)

Quantity___________

Refill x___________months

Instructions_______________________________________________________________________________________

Physician’s signature_______________________

Provider NPI: __________________

MD# ________________________

Date:_____________________

Date medication needed_____________________

Patient Information

Prescriber Information

Patient’s name________________________________

Prescribing physician________________________

Patient’s address__________________________

Office address______________________________

City, State, Zip: _____________________________________

Patient’s phone # ________________________

Office contact_______________________________

Patient’s ID#:__________________ DOB ____________

Office #_____________________ Fax# ___________________

Upon approval, delivery is available. Complete section below.

Delivery Requested

No Delivery Requested

Physician Supply, authorization only [Flex series]

Physician’s office

Patient’s home

Member Pick up at pharmacy if benefit available

Preferred Vendor: ____________________________________

**A copy of the prescription must accompany the medication request**

1. DIAGNOSIS FOR DRUG REQUESTED

Osteoarthritis of the knee (Specify ICD9 code) _________________

Right

Left

Bilateral

Other (specify)____________________________

2. PATIENT’S INFORMATION:

a. Does the individual have documented symptomatic osteoarthritis of the knee?

Yes

b. Does the individual report pain that interferes with functional activities

(e.g., ambulation or prolonged standing)?

Yes

c. Has the patient tried conservative therapy (including oral medications) without

improvement for at least three months?

Yes

d. Does the patient have any contraindications to viscosupplementation injections?

Yes

3. PATIENT HISTORY

Please list any previous or current therapies related to the diagnosis:

Drug name

Dates

Duration

________________________

Please add any other supporting medical information that may be useful in the decision-making process:

_________________________________________________________________________________

FAX TO (215) 761-9165 YOUR OFFICE WILL RECEIVE A RESPONSE VIA FAX OR MAIL

M / Rx

Internal use only

Vendor__________________

Billing Code_____________

Document #_______________________

LOB________________

Processor Initials___________

Rx coverage Y

STANDARD - SELECT

Date____________________

Previous Auth

Auth#_____________________

From______________ To_____________

Approved

Reviewer Initials______________

Date_______________Coverage effective date

/ /

04/2009 INJ004- HYALURON

Provider Communication

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield.

Independent licensees of the Blue Cross and Blue Shield Association.