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

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

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.

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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.
  • 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

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Last updated 11/08/19