When Synvisc-One^®   and  SYNVISC^® (hylan G-F 20) must be obtained from specialty pharmacies, physicians neither bill nor receive payment for the product. Instead, payers reimburse the specialty pharmacies directly. Physicians do bill for professional services related to the administration of SYNVISC.

If you have patients whose insurers require them to order SYNVISC and Synvisc-One through specialty pharmacies, you may do so using one of these forms. If the form you are looking for is not listed below, please contact the patient's specific insurance company.

Order Forms

• Accredo Order Form (PDF)*
• Aetna SPP Order Form (PDF)
• BCBS Florida SPP Order Form (PDF)
• BCBS Tennessee SPP Order Form (PDF)
• BCBS Vermont Specialty Scripts SPP Order Form (PDF)
• BioScrip Order Form (PDF)
• Capital Blue Cross of PA Hyaluronic Acid Derivatives Statement of
  Medical Necessity Form (PDF)*
• Curascript Order Form (PDF)
• Cigna Tel-Drug Specialty Pharmacy Joint Degeneration Fax Order Form (PDF)
• CVS Caremark Order Form (PDF)
• Diplomat Order Form (PDF)
• HomeCall RX Order Form (PDF)
• Horizon BCBS NJ Order Form (PDF)
• Independence Blue Cross Injectable Drug Order Form (PDF)
• McKesson Injectable Drug Request Form (PDF)
• Medco Specialty Pharmacy Form (PDF)
• Precision RX Order Form (PDF)
• Prescription Solutions Authorization Form (PDF) (for use when PA is not required)
• Presbyterian McKesson Order Form (PDF)
• RegenceRx Walgreens Specialty prescription form (PDF)
• Triessant Orthopedic Prescription/Pharmacy Intake Form (PDF)
• Walgreens Medmark Orthopedic Prescription Pharmacy Intake Form (Ann Arbor) (PDF)
• Walgreens Medmark Orthopedic Prescription Pharmacy Intake Form (Pittsburg) (PDF)
• Walgreens Medmark Orthopedic Prescription Pharmacy Intake Form (Portland) (PDF)
• Wellmark BCBS IA Treatment Request Form (PDF)*
• Wellmark BCBS SD Treatment Request Form (PDF)*

Prior Authorization Forms

• Anthem Blue Cross of CA Prior Authorization Form (PDF)*
• Anthem Central Region HA Pre Certification Form (PDF)
• Anthem CT, NH, ME Pre Determination Form (PDF)
• Anthem VA Health Services Review Form (PDF)
• BCBS MA Prior Authorization Form (PDF)
• BCBS GA Pre Determination Form (PDF)*
• ConnectiCare Prior Authorization Form (PDF)
• HealthNet Northeast Prior Authorization Form (PDF)*
• Humana Prior Authorization Form (PDF)
• Humana 2009 Prior Authorization Pre Cert Form (PDF)*
• Prescription Solutions Prior Authorization Form (PDF)
• Tufts Health Plan Prior Authorization Form (PDF)

*Note: If you are submitting these forms for Synvisc-One, please write in the product name Synvisc-One on the form. You may also need to included the following information:

• Name of Drug: Synvisc-One
• Dosage: 48mg
• NDC number: 58468-0090-03
• HCPCS Code: J7325

This reimbursement material represents Genzyme's current understanding. Many topics covered in this guide are complex and all are subject to change beyond our control. Healthcare professionals are responsible for keeping current and complying with reimbursement policy and regulations. This information is not intended to be directive, nor does the use of the recommended codes guarantee reimbursement. Providers should select the codes that most accurately reflect the patient's medical condition, payer requirements, practice patterns and services rendered. Providers are responsible for the accuracy of any claims, invoices and related documentation submitted to payers.