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SYNVISC and SYNVISC-ONE are covered by many commercial payers; however, you should be aware of patient-specific insurance benefits and plan restrictions.
Before treating a patient with SYNVISC or SYNVISC-ONE, it is recommended that you conduct an insurance verification to understand patient-specific insurance coverage. This will help to assess if SYNVISC and SYNVISC-ONE are covered, whether there is a specialty pharmacy option, whether there are setting-of-care restrictions, and what the patient's cost-sharing requirements, including deductibles, co-payments, co-insurance, and out-of-pocket maximums are.
If your patient needs assistance in affording SYNVISC or SYNVISC-ONE, Sanofi Patient Connection® could potentially help. Click here to learn more.
SYNVISC and SYNVISC-ONE commercial payer reimbursement
Under commercial payers, reimbursement for SYNVISC, SYNVISC-ONE and the associated administration will vary, based on the contract established between the provider and payer.
Reimbursement for injectable products is generally based on average wholesale price (AWP), wholesale acquisition cost (WAC), or average sales price (ASP), plus or minus a contracted percentage.
In some instances under managed care, providers are capitated for all the costs of care, including injectable medications. They may receive a monthly per member per month (PMPM) payment and no additional reimbursement for specific services rendered. Alternatively, some commercial payers may require physicians to obtain SYNVISC and SYNVISC-ONE through specialty pharmacies. In these cases, physicians neither bill nor receive payment for the product; rather, payers reimburse the specialty pharmacies directly for the product and physicians need only bill for their professional services.
Using a specialty pharmacy allows you to focus on patient care by potentially limiting the financial risk that carrying inventory for your commercial patients can pose.
In the hospital outpatient setting, commercial payers typically reimburse for SYNVISC or SYNVISC-ONE, based on a contracted AWP-, WAC-, or ASP-based amount, plus or minus a certain percentage. Reimbursement for hospital administration services may be determined according to a prospectively set payment rate, similar to the OPPS APC system. Alternatively, payment may be based on case rate or other type of negotiated fee schedule.
Providers retain sole responsibility for determining reimbursement and insurance issues related to their patients and for ensuring the accuracy of their submission claims. Sanofi cannot be responsible for failure of a provider to obtain reimbursement.
