Table 77: Hyaluronan Injections
Drug Category: Hyaluronan Injections
Medication Class/Individual Agents: Hyaluronan Injections
I. Prior-Authorization Requirements
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
1. Iannitti T, Lodi D, Palmieri B. Intra-articular injections for the treatment of osteoarthritis. Drugs R D 2011; 11(1):13-27.
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.
III. Evaluation Criteria for Approval
- All prior-authorization requests must include clinical diagnosis, product name, dose, and frequency.
- 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 the member’s condition and requested medication (see below).
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 an intra-articular corticosteroid injection, or contraindication to all intra-articular corticosteroid injections; and
- inadequate response (defined as ≥ 30 days of therapy) or adverse reaction to one nonsteroidal anti-inflammatory drug (NSAID), or contraindication to all NSAIDs.
Original Effective Date: 05/2018
Last Revised Date: 08/2019
Last updated 01/11/21