Sodium Hyaluronate- Medical Necessity Request Form
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2Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Sodium Hyaluronate– Medical Necessity Request
(Euflexxa, Synvisc, Synvisc One, Hyalgan, Supartz)
1.
Has the member tried and had an inadequate response to acetaminophen (Tylenol) or an NSAID (drugs such as ibuprofen,
naproxen, meloxicam, etc)? Yes or No
-
If No, can the member try acetaminophen or an NSAID instead of sodium hyaluronate? Yes or No
- If yes, please call the prescription in to the pharmacy.
- If No, please provide the clinical reason(s) why member cannot try acetaminophen or an NSAID.
___________________________________________________________________________________
2.
What is the diagnosis?
□ Osteoarthritis of the knee
- Which knee(s) is/are affected? ______________
□ DJD (Degenerative Joint Disease) of the knee
- Which knee(s) is/are affected? ______________
□ Other: __________________________________
3.
Which of the following conservative, non-pharmacologic therapies has the member tried:
□ Exercise
□ Strength training
□ Physical therapy
□ Weight loss
- Current weight: _______ lbs or kg
- Height: _______ft/in or cm
□ NONE
- Can the member try a conservative, non-pharmacologic therapy instead? Yes or No
- If no, please provide the reason why member cannot try a conservative, non-pharmacologic therapy.
________________________________________________________________________________________
________________________________________________________________________________________
4.
Has the member tried and failed intra-articular corticosteroids?
□ Yes
□ No – Can the member try an intra-articular corticosteroid? Yes or No
- If no, please provide the reason why the member cannot try an intra-articular corticosteroid?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
What is the prescriber’s specialty?
5.
□ Rheumatology
□ Orthopedics
□ Physiatry (Physical Medicine & Rehabilitation)
□ Pain Management
□ Sports Medicine
□ Other: _______________________________________
6.
Does the member have infections or skin diseases in the area of the injection site or joint? Yes or No
7.
Has the member received sodium hyaluronate within the immediate past 6 months? Yes or No
- If Yes, please provide the clinical reason why the member is receiving this medication more frequently than every 6
months. ___________________________________________________________________________________________
Physician office's signature*_________________________________ Print Name________________________________
* Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 2
Rev. 3/16
HNJH Fax #: 888-567-0681
Page
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