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Medications listed are available on OH EPIC Formulary, unless otherwise noted.
Not all formulary medications are available at each facility. Please refer to your local pharmacy for available inventory.
Search results for:

sodium hyaluronate

sodium hyaluronate
Drug Name Form Strength Infusion Center Available Restricted Non-formulary Ambulatory Available Interchange REMS
Gelsyn-3 SOLUTION, INTRA-ARTICULAR 8.4 mg/mL      
Euflexxa SOLUTION, INTRA-ARTICULAR 10 mg/mL      
Durolane SOLUTION, INTRA-ARTICULAR 20 mg/mL      
VIEW MORE Skin and Mucous Membrane Agents, Miscellaneous
CLASS
849200
Additional Information and Links

Restricted to: Orthopedic, Rheumatology, and PM&R specialist/service line in the outpatient ambulatory and infusion clinics

Preferred formulary for Hyaluronate intra-articular (IA) injections to treat pain associate with osteoarthritis (OA) of the knee are Gelsyn 3, Durolane, Euflexxa, Monovisc, Orthovisc, and Synvisc-One.

Criteria for use:

  • PBM Preference, prior authorization, medical necessity criteria/diagnosis specific criteria AND Orthopedic, Rheumatology, and PM&R specialist/service or
  • Orthopedic, Rheumatology, or PM&R specialist/service line AND Tried and failed NSAID therapy, or allergic to NSAIDs AND Tried and failed glucocorticoid therapy.

 

 

Last updated: Dec. 27, 2022

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