Effective November 1, 2021, the Clinical Criteria ING-CC-0005 will include a trial and inadequate response or intolerance to two preferred hyaluronan agents in the Part B medical step therapy precertification review. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as-is current procedure). Step therapy will not apply for members who are actively receiving non-preferred medications listed below.


Clinical Criteria are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.


Clinical Criteria

Preferred drug(s)

Nonpreferred drug(s)


Euflexxa (J7323)

Supartz FX (J7321)

Durolane (J7318)

Gelsyn-3 (J7328)

Including but not limited to:

Gel-One (J7326)

GenVisc 850 (J7320)

Hymovis (J7322)

Monovisc (J7327)

Orthovisc (J7324)

Synvisc/Synvisc One (J7325)

TriVisc (J7329)

Hyalgan/Visco-3 (J7321)

Triluron (J7332)



Featured In:
October 2021 Anthem Provider News - Indiana