Orthovisc

Generic: sodium hyaluronate

30 MG — Prefilled Syringe

Also known as: sodium hyaluronate
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 7 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Expanded Bronze with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Source: CMS QHP JSON  ·  Checked: 7 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals
via Euflexxa 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
Source: CMS QHP JSON  ·  Checked: 7 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Tier 5 - Specialty ✓ — ✓ PA | QL
Secure Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health
via Euflexxa 		Tier 5 - Specialty ✓ — ✓ PA | QL
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