Is Synvisc Covered by Medicare?
- Is Synvisc covered by Medicare? Get answers to your questions about hyaluronic acid and learn about Medicare eligibility for knee arthritis injections.
A study published in The Lancet estimates that 22.9% of people over the age of 40 suffer from osteoarthritis of the knee. The condition occurs when the connective tissue that insulates the knee joint becomes worn away and damaged, causing stiffness and pain that can limit mobility.
If you're one of the millions affected by knee arthritis, your doctor may prescribe Synvisc to address your symptoms. Medicare may cover this treatment, provided you meet certain criteria.
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When Does Medicare Pay for Synvisc?
Generally, Medicare pays for Synvisc when deemed medically necessary under the definition established by the program. When Medicare covers Synvisc, how much you can expect to pay for Synvisc out of pocket depends on where you're receiving treatment and what type of coverage you have as this article will discuss.
Medicare Part A and Part B are often referred to as Original Medicare. Your Original Medicare benefits can help pay for an osteoporosis injectable drug and visits by a home health aide nurse to inject the drug if you meet certain conditions, according to Medicare.gov the official Medicare website:
- You’re a woman.
- You’re eligible for Part B and meet the criteria for Medicare home health services.
- You have a bone fracture that a doctor certifies is related to postmenopausal osteoporosis.
- Your doctor certifies that you’re unable to learn to give yourself the drug by injection and your family members or caregivers are unable and unwilling to give you the drug by injection.
If you have a Medicare Advantage Prescription Drug plan (MA-PD) or a Medicare Part D Prescription Drug Plan (PDP), your play may offer additional Synvisc coverage. Speak with your plan carrier directly for more information.
If you're comparing new Medicare Advantage plans or new Medicare Part D drug plans and looking for a plan that helps pay for Synvisc, you can request free plan quotes online or call to speak with a licensed Medicare insurance agent.
What Is Synvisc?
Synvisc is a brand-name hyaluronic acid injection available with a doctor's prescription. Hyaluronic acid is a fluid naturally found around the joints that works with cartilage to act as an insulator. Some studies have found that increasing levels of hyaluronic acid in the knee with Synvisc can reduce pain by lubricating the joint.
What Types of Synvisc Are Available?
Synvisc is available in two forms:
- Traditional Synvisc involves three 2mL injections into the knee joint given one week apart.
- Synvisc-One is a single 6mL dose.
Both types of Synvisc injections are administered by a medical professional, usually in a doctor's office, an outpatient clinic or a hospital.
How Much Does a Three-Dose Course of Synvisc Cost?
Drugs.com reports that the average cost of one 2mL Synvisc injection is around $417 and that a three-dose course usually costs a little more than $1,000. However, exact pricing varies depending on your plan and pharmacy.
If you have Original Medicare and your Synvisc injections are covered by your Medicare coverage, a Medicare Supplement plan (also called Medigap) could help pay your Medicare copays, deductibles and other out-of-pocket costs.
How Much Does a One-Shot of Synvisc Cost?
The average cost of one Synvisc-One shot is around $1,000 as of October 2021, according to Drugs.com. Whether you are given traditional Synvisc or Synvisc-One, you may have to pay additional fees for treatment, such as the price of an office visit with a physician.
When Will Medicare Cover Synvisc?
For Synvisc and other hyaluronic acid knee injections to be covered by Medicare, you must meet all of the following conditions:
- You have symptoms like knee pain or stiffness that make it difficult for you to perform daily tasks like standing, walking or getting restful sleep.
- You have undergone medical imaging tests like an X-ray or MRI to show that you have signs of osteoarthritis in your knee.
- Other possible causes for your symptoms have been ruled out through laboratory testing and imaging.
- You have already undergone three months of other treatments such as lifestyle changes, physical therapy and the use of over-the-counter pain relievers like acetaminophen and ibuprofen,
- Your doctor has already tried treating your knee arthritis by removing fluid from your knee and injecting corticosteroids to reduce inflammation.
Will Medicare Cover Synvisc Injections More Than Once?
Medicare will provide coverage for repeat Synvisc injections if you meet the following criteria:
- Your symptoms have returned
- At least six months have passed since your last injection
- You either saw a noticeable decline in pain or were less in need of over-the-counter pain relievers and corticosteroid injections following your previous injection
Does Medicare Part A Cover Hyaluronic Acid Injections?
Medicare Part A usually covers hyaluronic acid injections that are given during a stay in an approved hospital or long-term care facility. You'll need to meet the eligibility requirements above and have already paid your deductible. If you're in the hospital or long-term care facility for more than 61 days, you may be responsible for coinsurance.
Does Medicare Part B Cover Hyaluronic Acid Injections?
Medicare Part B typically covers hyaluronic acid injections for eligible people when they are given at a hospital on an outpatient basis or in the office of a medical provider. The facility or doctor giving the injection must participate in Medicare, and you'll usually have to satisfy your premium before coverage is available.
How Much Does Synvisc Cost With Medicare Part B?
Under Medicare Part B, your plan will typically pay for 80% of the Synvisc cost, leaving you responsible for 20% of the cost.
Does Medicare Advantage Cover Hyaluronic Acid Injections?
Generally, Medicare Advantage plans must cover at least as much as Medicare Parts A and B do. As a result, your plan is likely to at least match the coverage provided by Original Medicare if you're eligible for Synvisc injections. You may need to receive the injection at a hospital, clinic or doctor's office in your plan's network and will likely be responsible for a copay or coinsurance. Your insurance provider can give you more information about coverage for hyaluronic acid injections.
Does Medigap Cover Hyaluronic Acid Injections?
Most Medicare Supplement or Medigap plans pay for all or some of the cost of medical expenses that original Medicare doesn't cover. Your plan may help you pay the 20% of the cost of Synvisc injections that you would usually pay out of pocket with Medicare Part B.