PHARMACY POLICY STATEMENT Kentucky Medicaid DRUG NAME Euflexxa (sodium hyaluronate) BILLING CODE J7323 BENEFIT TYPE Medical SITE OF SERVICE ALLOWED Office/Outpatient Hospital COVERAGE REQUIREMENTS Prior Authorization Required (Non-Preferred Product) Alternative preferred products include Durolane, Supartz FX , Gelsyn-3 QUANTITY LIMIT 3 injections (3 units) LIST OF DIAGNOSES CONSIDERED NOT MEDICALLY NECESSARY Click Here Euflexxa (sodium hyaluronate) is a non-preferred product and will only be con sidered for coverage under the medical benefit when the following criteria are met: Members must be clinically diagnosed with one of the following disease states and meet their individual criteria as stated. OSTEOARTHRITIS OF THE KNEE For initial authorization: 1. Member must be 40 years old or older; AND 2. Member must have a diagnosis of osteoarthritis confirmed by radiological evidence (e.g. Kellgren-Lawrence Scale score of grade 2 or greater); AND 3. Medication must be prescribed by an orthopedic surgeon, interventional pain physicians, rheumatologists, physiatrists (PM&R) and all sports medicine subspecialties; AND 4. Member tried and failed an intra-articular corticosteroid injection(s) in which efficacy was
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