Under commercial payers, reimbursement for Synvisc-One^®, SYNVISC^® (hylan G-F 20) and the associated administration will vary, based on the contract established between the provider and payer.

Reimbursement for injectable products is generally based on average wholesale price (AWP), wholesale acquisition cost (WAC), or average sales price (ASP), plus or minus a contracted percentage.

In some instances under managed care, providers are capitated for all the costs of care, including injectable medications. They may receive a monthly per member per month (PMPM) payment and no additional reimbursement for specific services rendered. Alternatively, some commercial payers may require physicians to obtain Synvisc-One and SYNVISC through specialty pharmacies. In these cases, physicians neither bill nor receive payment for the product; rather, payers reimburse the specialty pharmacies directly for the product and physicians need only bill for their professional services.

Using an specialty pharmacy allows you to focus on patient care by eliminating the financial risk that carrying inventory for your commercial patients can pose.

Click here to search for the Specialty Pharmacy options each commercial payer has available.

For billing instructions in the office setting:

• Download the Sample CMS-1500 Claim Form (PDF)
• Download Additional Documents

Hospital Outpatient

In the hospital outpatient setting, commercial payers typically reimburse for Synvisc-One or SYNVISC, based on a contracted AWP-, WAC-, or ASP-based amount, plus or minus a certain percentage. Reimbursement for hospital administration services may be determined according to a prospectively set payment rate, similar to the OPPS APC system. Alternatively, payment may be based on case rate or other type of negotiated fee schedule.

For billing instructions in the hospital outpatient setting:

Download the Sample CMS-1450/UB04 Form (PDF)
Download Additional Documents

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.