Sodium Hyaluronate- Medical Necessity Request Form (Page 2 of 2) in pdf

Sodium Hyaluronate- Medical Necessity Request Form Page 2

Member 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)

**Complete page 2 only for Subsequent/Renewal Requests**

1. 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: __________________________________

2. Has the member experienced significant improvement from prior course of therapy, defined as one of the following?

a. Lower pain score from baseline

Yes or No

b. Improvement in ambulation or quality of daily living

Yes or No

c. Reduction in the use of analgesics

Yes or No

3. 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

2 of 2

Rev. 3/16

HNJH Fax #: 888-567-0681

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Sodium Hyaluronate- Medical Necessity Request Form Page 2