Skip to Content

Table 77: Hyaluronan Injections


A    B    C    D    E    F    G    H    I    J    K    L    M    N    O    P    Q    R    S    T    U    V    W    X    Y    Z


Drug Category: Hyaluronan Injections

Medication Class/Individual Agents: Hyaluronan Injections

I. Prior-Authorization Requirements

 Hyaluronan Injections

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

hyaluronan, high molecular weight Orthovisc PA   MB
hyaluronate, crossed-linked Gel-One PA   MB
hyaluronate, modified Hymovis PA   MB
hyaluronate, stabilized Durolane PA   MB
hyaluronate-Euflexxa Euflexxa PA   MB
hyaluronate-Gelsyn Gelsyn PA   MB
hyaluronate-Genvisc Genvisc PA   MB
hyaluronate-Hyalgan Hyalgan PA   MB
hyaluronate-Monovisc Monovisc PA   MB
hyaluronate-Supartz Supartz PA   MB
hyaluronate-Synojoynt Synojoynt PA   MB
hyaluronate-Triluron Triluron PA   MB
hyaluronate-Trivisc Trivisc PA   MB
hyaluronate-Visco-3 Visco-3 PA   MB
hylan G-F20-Synvisc Synvisc PA   MB
hylan G-F20-Synvisc-One Synvisc-One PA   MB

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

 

Hyaluronic acid (HA) is a constitutive component of matrix cartilage, which plays a key role in the maintenance of joint homeostasis. HA is also a biologically active component, secreted by chondrocytes, that protects the cartilage from degradation by interacting with matrix metalloproteinase (MMPs) and pain mediators.1

In patients with osteoarthritis (OA), the concentration and molecular weight of HA are reduced, diminishing elastoviscosity of the synovial fluid, joint lubrication and shock absorbency, and possible anti-inflammatory, analgesic, and chondroprotective effects.2, 3

The aim of HA treatment is to reduce pain and improve physical function by supplementing the viscosity and elasticity of synovial fluid which are reduced in OA.2

References:

1. Iannitti T, Lodi D, Palmieri B. Intra-articular injections for the treatment of osteoarthritis. Drugs R D 2011; 11(1):13-27.
2. Gigante A, Callegari L. The role of intra-articular hyaluronan in the treatment of osteoarthritis. Rheumatol Int 2011; 31:427-44.
3. Strauss EJ, Hart JA, Miller MD, Altman RD, Rosen JE. Hyaluronic acid viscosupplementation and osteoarthritis. Am J Sports Med 2009; 37(8):1636-44.

 
Table Footnotes
MB This drug is available through the health care professional who administers the drug or in an outpatient or inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through the retail pharmacy. If listed, PA does not apply through the hospital outpatient and inpatient settings. Please refer to 130 CMR 433.408 for PA requirements for other health care professionals. Notwithstanding the above, this drug may be an exception to the unified pharmacy policy; please refer to respective MassHealth Accountable Care Partnership Plans (ACPPs) and Managed Care Organizations (MCOs) for PA status and criteria, if applicable.
 

II. Therapeutic Uses

FDA-approved, for example:

  • treatment of pain associated with osteoarthritis (OA) or degenerative joint disease (DJD) of the knee

Note: The above list may not include all FDA-approved indications.

Back to top


III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All prior-authorization requests must include clinical diagnosis, product name, dose, and frequency.
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply. 
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply depending upon diagnosis and/or requested medication (see below). Other factors, including rebate and FDA-approval status, may change independently of scheduled MassHealth updates, which may result in additional restrictions.

 

All Hyaluronan Injections

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response (defined as ≥ 30 days of therapy), adverse reaction, or contraindication to acetaminophen; and
    • inadequate response or adverse reaction to one or contraindication to all intra-articular corticosteroid injections; and
    • inadequate response (defined as ≥ 30 days of therapy) or adverse reaction to one or contraindication to all  nonsteroidal anti-inflammatory drug (NSAIDs).
    •  


Original Effective Date: 05/2018

Last Revised Date: 03/2024


Clinical Criteria Main Page | Back to topPrevious  |  Next

Last updated 06/24/24

Feedback