New Hyaluronic Acid Derivatives Criteria Sheet, CR 119147

Sep 29, 2023

MaineCare replaced the Prior Authorization (PA) Synvisc Hyalgan Euflexxa Orthovisc form.  

Effective September 27, 2023, please use the following new form, called Hyaluronic Acid PA form, which is available by logging into your Trading Partner Account in the secure section of the Health PAS Online Portal. Once logged in, please follow this pathway: MaineCare Information>Prior Authorizations>Manual, Forms, and Criteria Sheets under the J-Code Forms section. 

Please discard the outdated Synvisc Hyalgan Euflexxa Orthovisc form if you previously downloaded or printed it. 

If you have questions, please email Provider Services or call 1-866-690-5585. TTY users dial 711.