Independence Prior Authorization Form Viscosupplementation (Hyaluronates)
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1Today’s Date: ___________
Date medication needed: _________
Prior Authorization Form
Viscosupplementation (Hyaluronates)
ONLY COMPLETED REQUESTS WILL BE REVIEWED
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PREFERRED BRANDS:
Orthovisc
Synvisc
Synvisc-One
Euflexxa
Gel-One
Hyalgan
Supartz
Check one:
New request
Refill request (skip question 2)
Patient Information (please print)
Provider Information (please print)
Patient’s Name: ____________________
Prescribing Physician:_____________________
Address: __________________________
Office Address: __________________________
City/State/Zip Code: _________________
City/State/Zip Code:_______________________
DOB:_____________________________
Office Contact:___________________________
Telephone#: _______________________
Office Telephone#:________________________
Patient’s ID#:_______________________
Fax #:___________________NPI:____________
Upon approval, delivery is available by completing the section below.
N/A – No delivery requested, authorization only - physician will use office supply
Delivery requested (indicate where medication should be delivered: Physician’s office Patient’s home)
**A copy of the prescription must accompany the medication request for delivery.**
1. Diagnosis for drug requested (must include ICD-9):
715.____ Osteoarthritis of the knee:
Right
Left
Bilateral / Date of last injection ________________
Other (specify ICD-9) ____________________________________
2.
Patient medical information: (check all that applies)
a. Does the individual have documented symptomatic osteoarthritis of the knee?
Yes
No
b. Does the individual report pain that interferes with functional activities (e.g., ambulation or
Yes
No
prolonged standing)?
c. Is there adequate documentation that the individual does not have functional improvement after a
Yes
No
trial period of conservative treatments such as exercise, physical therapy and medication?
d. Request for a non-preferred agent: Has the individual had an inadequate response or inability to
Yes
No
tolerate a preferred agent (Orthovisc, Synvisc, or Synvisc-One)?
3. For additional courses of treatment:
Yes
No
Has the individual experienced significant improvement in pain and functional capacity of the joint(s)
since the previous series?
4. Prescription information:
Quantity _______________ Refill x _______month(s)
Instructions (include dose) _______________________________ every _________ day(s)/ week(s)/ month(s)
Physician’s signature
_________________________________________________________________________________
Fax completed form to 215-761-9165. Your office will receive a response by fax within two business days.
8/2013 INJ-11.14.07j
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.
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