Private Insurance

Private insurers generally cover SYNVISC® for FDA-approved indications. However, you should be aware of plan-specific and patient-specific restrictions.

Asking the following questions may help you determine how to access coverage and reimbursement for SYNVISC:

• How does SYNVISC fit into the patient's specific plan?
• Are there requirements for setting of care?
• Is prior authorization required?
• Are there specific restrictions on how SYNVISC is obtained?

How does SYNVISC fit into the patient's specific plan?
Product coverage, benefit type, and patient cost-sharing requirements vary from employer contract to employer contract. If you are interested in having our specialists on the SYNVISC Connection^SM confirm your patient's insurance coverage, please complete our Insurance Verification Request Form (Word, 67K), and fax it to 1-800-508-8083, or you may contact the Hotline directly at 1-800-982-8292, M-F, 9 am -6 pm (EST).
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Are there requirements for setting of care?
Where SYNVISC is administered may impact coverage. For example, SYNVISC administered in the physician's office may be covered and reimbursed differently than in the hospital outpatient setting.

When SYNVISC is acquired in the office setting, providers generally bill SYNVISC and its administration using the Blank CMS-1500 Claim Form (PDF, 87K). In contrast, when SYNVISC is acquired and billed in the hospital outpatient setting, hospital providers use the Blank CMS-1450 Hospital Claim Form (PDF, 17K).

For billing instructions:
Download the Sample CMS 1500 Claim Form (PDF, 225K) and the Sample CMS-1450 or UB-92 Claim Form (PDF, 15K).
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Is prior authorization required?
Depending on each patient's insurance plan, prior authorization for SYNVISC may be required by some private insurers. Call the SYNVISC Reimbursement Hotline at 1-800-982-8292, M-F, 9 am -6 pm (EST) to get help with understanding specific plan requirements.
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Are there specific restrictions on how SYNVISC is obtained?
Yes, certain restrictions may apply:

Stock and bill:

• If you are required to stock and bill for SYNVISC and are a freestanding physician clinic, use the Blank CMS 1500 Claim Form (PDF, 87K). If you are a hospital outpatient department, use the Blank CMS 1450 Claim Form (PDF, 17K).

Specialty Pharmacy:

• SYNVISC may be obtained through a specialty pharmacy, specialty distributor, or through a retail or mail-order pharmacy program.
• If SYNVISC must be obtained through a specialty pharmacy, be sure to use the appropriate Specialty Pharmacy Order Form. In cases where SYNVISC must be obtained from specialty pharmacies, physicians neither bill nor receive payment for the product; payers reimburse the specialty pharmacies directly. Physicians do bill for professional services related to the administration of SYNVISC.
• If the patient must purchase SYNVISC from a pharmacy and bring it into your office for administration, you should use the Blank CMS 1500 Claim Form (PDF, 87K) to bill SYNVISC and its administration.

Preferred Pharmacy Network (PPN):

• If the payer uses a preferred pharmacy network (PPN), requiring the patient to use specific retail or mail-order pharmacies, physicians neither bill nor receive payment for the product; payers reimburse the pharmacies directly. Physicians do bill for professional services related to the administration of SYNVISC and use the Blank CMS 1500 Claim Form (PDF, 87K).

It is important to verify the specific coverage and access requirements under your patient's insurance plan.
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Questions about private insurance coverage?
Call the SYNVISC Connection^SM at 1-800-982-8292, M-F, 9 am -6 pm (EST).

Providers retain responsibility for determining reimbursement and insurance issues related to their patients. Genzyme cannot be responsible for failure of a provider to obtain reimbursement.