Hyaluronic Acid Intra-articular Products

Covers listed intra‑articular hyaluronic acid products for FDA‑approved treatment of knee osteoarthritis pain and excludes use for other joints or any products not on the list. Coverage requires radiologic confirmation of knee OA, failure of conservative care with at least TWO of these three modalities (one course of physical therapy; at least TWO pharmacologic therapies from NSAID [oral/topical], acetaminophen, tramadol, or duloxetine — note two or more NSAIDs count as one pharmacologic trial; and at least TWO intra‑articular corticosteroid injections), administration by or under supervision of a rheumatologist/orthopedic surgeon/physiatrist, product‑specific dosing limits, a minimum 6‑month interval between HA courses, 6‑month authorization periods, and documented response for reauthorization.

"Indicated for the treatment of pain in osteoarthritis of the knee in individuals who have failed to respond adequately to conservative non-pharmacologic therapy and analgesics (e."