FEP Hyaluronic Acid Derivatives

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• Required *

• Enter Patient Information

• Drug Name: *
• Blue KC ID (Not SS#): *
  • i
  • i
  • i
• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *
• Date of Birth: *
• Patient Group ID: *
• ICD-10 Diagnosis Codes: *

  Diagnosis Codes must be 3-8 characters along with decimals

  Codes must be 3 - 8 characters and 2 decimals.
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• Has the patient been using samples? Yes No
• Dose and Directions: *

• Required *

• Enter Provider Information

• Provider ID OR NPI: *
• Provider's Name: *
• Physician's Specialty: *
• Street Address: *
• City: *
• State: *
• ZIP Code: *
• Email Address:
• Phone Number:
  Enter a 10 digit phone number.
• Fax Number:*
  Enter a 10 digit phone number.
• Contact First Name: *
• Contact Last Name: *
• Contact Email Address: *
• Contact Phone Number: *
• Contact Phone Ext:
• Contact Fax Number:*

1. What is the J-Code:*

2. If Osteoarthritis (OA, DJD) what is the location? *

• Left knee only
• Right knee only
• Both knees

3. Is this the INITIATION or CONTINUATION of therapy?

• INITIATION
  1. Please list TWO or more conservative non-pharmacologic therapies tried: *
     
  2. Please specify what medications the patient failed to achieve an adequate response, has an intolerance or contraindication to (Check all that apply OR None of these): *
     • Acetaminophen
     • Oral NSAIDs
     • Topical NSAIDs
     • Tramadol
     • None of these
  3. Has the patient had an inadequate response, intolerance, or contraindication to intra-articular steroid injections in which the efficacy lasted less than 8 weeks? *
     
     • Yes
     • No
  4. Is there radiologic confirmation of Kellgren-Lawrence score of grade 2 or greater? *
     
     • Yes
     • No
• CONTINUATION (Renewal of PA)
  1. Is there documented improvement in pain with the previous course of treatment? *
     
     • Yes
     • No
  2. Has at least 12 months elapsed since the last injection of the prior treatment cycle? *
     
     • Yes
     • No
  3. Has there been a documented reduction of dosing of NSAIDs or other analgesics during the 12 month period following the last injection of the prior treatment cycle? *
     
     • Yes
     • No

If you have any additional information pertinent to this patient’s therapy, please specify.

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