Why Your Insurance Prefers Certain Gel Injection Brands (And What It Means for You)

If your doctor recommended gel shots for your knee pain, you might be surprised to learn your insurance company has its own opinion about which brand you should get. It’s not about which works best for you—it’s about their cost structure.

Welcome to the world of “step therapy” and “preferred brands.” This guide explains how insurance companies control which gel injection brands get covered, why they do it, and most importantly, how to navigate the system to get the treatment that’s right for you.

Key Takeaways

• Insurance companies use “step therapy” to require you to try cheaper gel brands first before covering more expensive options
• “Preferred brands” cost insurers less due to manufacturer contracts, not necessarily because they’re more effective
• Common step therapy brands include Triluron, TriVisc, Visco-3, Gelsyn-3, and GenVisc 850
• Premium brands like Synvisc-One and Euflexxa are often tier 2 or non-preferred
• Medicare has fewer brand restrictions than commercial insurance
• You can request exceptions to step therapy requirements with proper documentation
• Understanding your plan’s formulary can save you hundreds of dollars

What Is a “Preferred Brand”?

When your insurance company designates a gel injection brand as “preferred,” they mean it’s the one they want your doctor to use. Not necessarily because it’s the best option for your knee, but because it’s the best option for their budget.

Here’s how it works:

Insurance companies negotiate contracts with drug manufacturers. The manufacturer offers a lower price (often called a “rebate”) in exchange for preferred status. In return, the insurance company puts that brand on a lower tier with better coverage.

For you, this means:

• Preferred brands have lower copays or coinsurance
• Non-preferred brands cost significantly more out of pocket
• Some non-preferred brands may not be covered at all

Think of it like your insurance company steering you toward the store-brand cereal instead of the name brand—except we’re talking about a medical treatment for your knee, not breakfast.

What Is Step Therapy?

Step therapy (also called “fail first” policies) requires you to try one or more cheaper treatment options before your insurance will cover a more expensive alternative.

The basic process:

1. Your doctor prescribes a gel injection brand they think is best for you
2. Insurance says “Try our preferred brand first”
3. You receive the preferred brand treatment
4. If it doesn’t work adequately, insurance may then cover the originally prescribed brand

Common step therapy sequence for gel injections:

Step 1: Generic or lower-cost HA brand (Triluron, TriVisc, Visco-3, GenVisc 850)
   ↓ (If inadequate relief after 3-6 months)
Step 2: Mid-tier brand (Supartz FX, Orthovisc, Hyalgan)
   ↓ (If inadequate relief after 3-6 months)
Step 3: Premium brand (Synvisc-One, Euflexxa, Monovisc, Gel-One)

What defines “inadequate relief”? That varies by insurer, but generally means:

• Less than 20% pain reduction
• No improvement in function or mobility
• Side effects that prevent continued use
• No sustained benefit beyond 2-3 months

Why Insurance Companies Do This

Let’s be clear: step therapy exists primarily to control costs, not to optimize patient outcomes.

The insurance company perspective:

• Gel injections can cost $500-$1,500 per treatment series
• Multiplied across thousands of patients, this adds up fast
• If a $500 brand works for some patients, why pay $1,200 for everyone?
• Step therapy ensures they only pay for premium brands when necessary

The stated rationale: Insurance companies claim step therapy ensures:

• Appropriate use of expensive treatments
• Cost-effective care delivery
• Prevention of unnecessary spending

The patient impact: Step therapy can mean:

• Delays in getting optimal treatment (6+ months trying cheaper brands first)
• Multiple rounds of injections instead of one effective treatment
• More out-of-pocket costs overall (copays for each failed attempt)
• Prolonged pain and reduced mobility while waiting

Common Step Therapy Brands vs. Premium Brands

Not all hyaluronic acid (HA) brands are created equal. Here’s what you need to know about the brands your insurance is likely to prefer—and the ones they’ll make you “fail” before covering.

Tier 1: Common Step Therapy Brands (Preferred/Low Cost)

Brand	Injections	Typical Cost	Key Features
Triluron	3 weekly	$400-$600	Lower molecular weight HA, often first-tier
TriVisc	3 weekly	$400-$600	Similar to Triluron, generic-equivalent option
Visco-3	3 weekly	$450-$650	Basic HA formulation, widely available
Gelsyn-3	3 weekly	$400-$600	Budget-friendly HA option
GenVisc 850	1-3 doses	$350-$550	Variable dosing protocol

Characteristics:

• Lower acquisition cost for insurers
• Usually require 3 weekly injections
• May have shorter duration of relief (3-6 months vs. 6-12 months)
• Often designated “preferred” or tier 1

Tier 2: Mid-Level Brands (Sometimes Preferred)

Brand	Injections	Typical Cost	Key Features
Supartz FX	5 weekly	$700-$900	Established track record, longer series
Orthovisc	3-4 weekly	$650-$850	Mid-range molecular weight
Hyalgan	3-5 weekly	$600-$800	One of the original FDA-approved brands

Tier 3: Premium Brands (Often Non-Preferred)

Brand	Injections	Typical Cost	Key Features
Synvisc-One	1 injection	$1,000-$1,500	Single-injection convenience
Euflexxa	3 weekly	$900-$1,200	Bio-fermented HA, lower reaction rates
Monovisc	1 injection	$900-$1,300	Single injection, extended-release
Gel-One	1 injection	$800-$1,200	Cross-linked HA formulation
Durolane	1 injection	$900-$1,300	High molecular weight, long-acting

Why insurers resist covering these:

• Higher upfront cost (even if cost per month of relief is similar)
• Single-injection formulas mean higher per-dose pricing
• Brand recognition drives patient requests

Why doctors often prefer these:

• Single injection = better patient compliance
• Potentially longer duration of relief
• Fewer office visits required
• Better patient satisfaction scores

How This Differs: Medicare vs. Commercial Insurance

The step therapy experience varies significantly depending on your insurance type.

Original Medicare (Parts A & B)

The good news:

• No formal step therapy requirements for HA brands
• No preferred brand lists
• Coverage based on medical necessity, not brand
• Your doctor has more discretion

The requirements:

• Must have documented knee osteoarthritis
• Must have tried conservative treatment (6+ weeks)
• Treatment must be administered in appropriate setting

Your cost:

• 20% coinsurance after Part B deductible ($257 in 2025)
• Same coinsurance regardless of brand
• No difference in coverage between Triluron and Synvisc-One

Why it’s different: Medicare follows evidence-based guidelines rather than cost-minimization strategies. If HA injections are medically appropriate, the brand choice is between you and your doctor.

Medicare Advantage Plans

More restrictive than Original Medicare:

• Many plans DO have preferred brand lists
• Step therapy requirements common
• Prior authorization often required
• Network restrictions may apply

Example scenario: Your Medicare Advantage plan might cover Triluron without prior auth but require you to try it first before approving Synvisc-One—even though Original Medicare would cover either.

Important: If you have Medicare Advantage, call your plan before assuming you have the same freedom as Original Medicare beneficiaries.

Commercial Insurance (Employer Plans, Marketplace Plans)

Most restrictive:

• Nearly all have tiered formularies
• Step therapy is standard
• Preferred brands heavily steered
• Prior authorization required for non-preferred brands

Typical structure:

• Tier 1 (preferred): $50-$100 copay
• Tier 2 (non-preferred): $200-$400 copay or 30-40% coinsurance
• Tier 3 (specialty): 40-50% coinsurance, often with step therapy requirement

Example: Your employer plan covers Triluron with a $75 copay. Synvisc-One requires:

1. Prior authorization
2. Documentation of failed Triluron trial (3-6 months)
3. Then 40% coinsurance ($400-$600 out of pocket)

The Step Therapy Decision Tree

Here’s how to navigate the system:

Do you have Medicare (Original)?
  → YES: No step therapy. Discuss best brand with doctor. ✓
  → NO: Continue below ↓

Do you have Medicare Advantage?
  → YES: Check your plan's formulary. May have step therapy. ↓
  → NO: You have commercial insurance. Continue below ↓

Check your insurance formulary:
  → Is your doctor's preferred brand Tier 1/Preferred?
     → YES: Proceed with treatment. ✓
     → NO: Continue below ↓

Does your plan require step therapy?
  → NO: Request exception (see below) or pay higher tier cost
  → YES: Continue below ↓

Have you tried the required step therapy brand?
  → NO: Consider trying it first OR request exception
  → YES: Did it fail to provide adequate relief?
     → YES: Request step therapy override with documentation ✓
     → NO: Continue with working treatment ✓

When to Request an Exception to Step Therapy

You don’t always have to accept step therapy. Here are situations where requesting an exception makes sense:

Medical Necessity Exceptions

You may qualify if:

• Previous adverse reaction to preferred brand
• Medical contraindication to preferred brand ingredients
• Documented failure of preferred brand in past (even years ago)
• Unique medical circumstances make preferred brand inappropriate

Example scenario: If you had an allergic reaction to a preferred brand’s formulation two years ago, your doctor can document this and request an exception to skip directly to an alternative brand.

Prior Experience Exceptions

You may qualify if:

• Previously successful with non-preferred brand
• Failed preferred brand trial within past 2-3 years
• Currently on non-preferred brand with good results (when switching insurance)

Example scenario: You received Synvisc-One last year with excellent 9-month relief. You now have new insurance that requires step therapy. Your doctor can document your previous success and request to continue the effective treatment.

Continuity of Care Exceptions

You may qualify if:

• Mid-treatment with non-preferred brand when insurance changed
• Established patient with ongoing effective treatment
• Switching brands could destabilize condition

How to Request a Step Therapy Exception

If you and your doctor believe the preferred brand isn’t right for you, here’s how to request an override:

Step 1: Talk to Your Doctor

Explain the situation:

• “My insurance requires I try [preferred brand] first, but I’m concerned about…”
• Ask if they’ve successfully obtained exceptions before
• Discuss whether trying the preferred brand first is reasonable

Your doctor may say:

• “Let’s try the preferred brand—it often works well”
• “I have strong clinical reasons to avoid that brand; I’ll request an exception”

Step 2: Doctor Submits Prior Authorization

Your doctor’s office submits a prior authorization request including:

Required documentation:

• Diagnosis and severity documentation
• Treatment history (conservative measures tried)
• Clinical rationale for non-preferred brand
• Why preferred brand is inappropriate or unlikely to work

Compelling reasons include:

• Previous documented failure of preferred brand
• Allergy or sensitivity to preferred brand ingredients
• Medical complexity requiring specific formulation
• Evidence that patient’s condition responds better to non-preferred brand

Step 3: Insurance Review

Timeline:

• Standard review: 5-14 business days
• Expedited review (urgent): 72 hours
• Appeal if denied: 30-60 days

Possible outcomes:

• Approved: Proceed with requested brand
• Partially approved: May approve for limited duration or with conditions
• Denied: Must try preferred brand first or pay full cost

Step 4: Appeal If Denied

First appeal (internal):

• Submit additional documentation
• Request peer-to-peer review (insurance doctor speaks with your doctor)
• Provide medical literature supporting your case

Second appeal (external):

• Request independent medical review
• File complaint with state insurance department
• Some states have step therapy override laws

What to Ask Your Doctor’s Billing Department

Don’t leave the office without understanding the insurance landscape. Here are critical questions to ask:

Before Scheduling Treatment

1. “Is the recommended brand covered by my insurance?”

• If yes: “Is it preferred or non-preferred? What’s my expected cost?”
• If no: “What are my covered alternatives?”

2. “Does my insurance require step therapy for gel injections?”

• If yes: “Which brand do I need to try first? How long must I try it?”
• If no: “Do I still need prior authorization?”

3. “What will this cost me out of pocket?”

• Ask for estimate based on your specific insurance
• Confirm copay vs. coinsurance vs. deductible
• Ask about payment plans if cost is high

4. “If the preferred brand doesn’t work, what’s the process to get approval for another brand?”

• How long must I try it?
• What documentation will you provide?
• What’s the success rate for these exception requests?

About Prior Authorization

5. “Will you handle prior authorization, or do I need to do anything?”

• Most offices handle it, but confirm
• Ask how long it typically takes
• Get a contact name for follow-up

6. “What happens if prior authorization is denied?”

• Will you file an appeal?
• Will I be notified?
• What are my options?

About Treatment Alternatives

7. “If insurance won’t cover any gel brand I can afford, what are my alternatives?”

• Other covered treatments?
• Self-pay pricing?
• Payment plans available?
• Manufacturer assistance programs?

8. “Can we get pricing for both the preferred brand and the brand you originally recommended?”

• Sometimes the copay difference is small
• Occasionally self-pay for preferred brand is cheaper than insurance for non-preferred
• Knowledge is power

Tips for Minimizing Out-of-Pocket Costs

Even within the step therapy system, you have options to reduce costs:

Strategy 1: Start with the Preferred Brand

Consider this approach if:

• The preferred brand has reasonable evidence
• Your insurance incentives are strong (big copay difference)
• You’re okay trying it for 3-6 months
• You have time to try multiple approaches

Advantages:

• Lowest upfront cost
• Satisfies insurance requirements
• May work perfectly fine for you
• Easier path to tier 2 if it fails

Disadvantages:

• 3-6 month delay if it doesn’t work
• Multiple office visit copays
• May need multiple trials before getting optimal brand

Strategy 2: Request Exception Immediately

Consider this approach if:

• You’ve tried preferred brands before without success
• You have medical reasons to avoid preferred brands
• Your doctor strongly recommends specific brand
• You can’t afford multiple trial failures

Advantages:

• Faster path to optimal treatment
• Fewer total injections and office visits
• Better chance of good outcome

Disadvantages:

• Risk of denial and full out-of-pocket cost
• Requires doctor time for documentation
• May take 2+ weeks for decision

Strategy 3: Compare Total Cost Scenarios

Sometimes the math is surprising. Calculate total costs for each path:

Scenario A: Start with preferred brand

• Preferred brand copay: $75
• If it fails after 6 months, try tier 2 brand: $250
• If that fails, tier 3 brand: $500
• Total: $825 + time/pain waiting

Scenario B: Self-pay for doctor’s first choice

• Self-pay negotiated rate: $600-$800 (some clinics offer cash discounts)
• Get optimal treatment immediately
• Potentially better outcome
• Total: $600-$800 one time

Strategy 4: Consider Single-Injection Brands

If you’re paying out of pocket or have high coinsurance:

Single-injection brands (Synvisc-One, Monovisc, Gel-One):

• Higher per-injection cost
• BUT fewer office visit copays
• Less time off work
• Better compliance (all done in one visit)
• May have longer duration of relief

Three-injection brands (most preferred brands):

• Lower per-injection cost
• BUT three separate office visits = three copays
• Three weeks of scheduling
• Risk of not completing series

Total cost comparison:

• Synvisc-One: $1,200 + 1 office visit copay ($30) = $1,230
• Triluron: $600 + 3 office visit copays ($90) = $690

The $540 difference may be worth it—or may not, depending on your financial and schedule constraints.

Strategy 5: Ask About Manufacturer Assistance Programs

Some manufacturers offer patient assistance for out-of-pocket costs:

• Copay assistance cards (reduce copay to $0-$50 for eligible patients)
• Patient assistance programs for uninsured/underinsured
• Reimbursement programs for denied claims

How to access:

• Ask your doctor’s office
• Visit manufacturer websites
• Call manufacturer patient support lines

Eligibility varies:

• Income limits may apply
• May not be available for government insurance (Medicare/Medicaid)
• May require prior authorization denial first

Red Flags: When Insurance “Steerage” Goes Too Far

While step therapy is legal and common, some insurance practices cross the line into problematic territory:

Warning Sign 1: “Not Medically Necessary” Without Review

If your insurance denies coverage claiming gel injections aren’t medically necessary—but you have documented osteoarthritis and failed conservative treatment—this is often a blanket policy rather than an individual medical decision.

What to do:

• Request specific criteria you didn’t meet
• Have doctor submit detailed medical records
• Appeal with supporting research
• File complaint with state insurance department if denial seems arbitrary

Warning Sign 2: Retroactive Denials

You receive treatment, insurance initially approves it, then denies payment months later, leaving you with a large bill.

What to do:

• Check if prior authorization was properly obtained
• Request audit of denial
• Don’t pay immediately—appeal first
• Check state laws on retroactive denials

Warning Sign 3: “Preferred Provider” Requirements

Insurance requires you to use specific clinics or doctors for gel injections—and those providers only offer the cheapest brands or have questionable quality.

What to do:

• Verify credentials and reviews of required providers
• Ask if out-of-network coverage is available
• Consider whether lower-quality care is worth the copay savings
• File complaint if required providers have pattern of poor outcomes

Warning Sign 4: Changing Formularies Mid-Year

Your insurance suddenly changes their preferred brands or adds step therapy requirements in the middle of your plan year without notice.

What to do:

• Check your plan documents for formulary change policies
• Request continuity of care exception
• File complaint if changes violate plan terms
• Ask employer (if employer plan) to intervene

The Big Picture: Making the System Work for You

Step therapy and preferred brands aren’t going away. But understanding how the system works gives you power to navigate it effectively.

Key Principles:

1. Knowledge is leverage Know your plan’s formulary, step therapy requirements, and exception processes before you need treatment.

2. Your doctor is your advocate A well-documented medical justification from your doctor carries weight. Use their expertise.

3. Don’t accept the first “no” Insurance denials can often be overturned with proper documentation and persistence.

4. Calculate total costs, not just copays The cheapest copay brand isn’t always the most cost-effective when you factor in effectiveness, duration of relief, and repeat treatments.

5. Medicare beneficiaries have more freedom If you’re 65+ or have qualifying disability, Original Medicare offers more flexibility than most commercial plans.

Final Thoughts

Your insurance company’s preferred gel injection brand might work perfectly for you. Or it might not. The key is understanding that “preferred” means preferred by the insurer’s finance department, not necessarily preferred by medical science or your specific needs.

Armed with the information in this guide, you can:

• Ask informed questions
• Understand your options
• Request appropriate exceptions
• Minimize out-of-pocket costs
• Get the treatment most likely to help your knee pain

If you’re considering gel injections, talk with your doctor about your specific insurance situation. Together, you can navigate step therapy requirements and find the most appropriate treatment—whether that’s the preferred brand or worth fighting for an exception.

Frequently Asked Questions

Can I just pay cash and skip insurance for gel injections?

Yes, you can always choose to pay out of pocket. Sometimes self-pay rates are lower than insurance-negotiated rates plus your coinsurance. Ask for self-pay pricing and compare. Note: if you pay cash, it may not count toward your deductible or out-of-pocket maximum.

How long does prior authorization take?

Standard prior authorization typically takes 5-14 business days. Expedited/urgent requests can be processed in 72 hours if your doctor documents urgency. Plan accordingly—don’t schedule treatment until approval is confirmed.

If I try the preferred brand and it doesn’t work, will insurance automatically cover the next tier?

Not automatically. Your doctor must document the failed trial (how long you tried it, lack of adequate response, side effects, etc.) and submit a new prior authorization for the alternative brand. Keep records of your response to treatment.

Does Medicare have preferred brands for gel injections?

Original Medicare (Parts A & B) does not have preferred brands or step therapy requirements. Medicare Advantage plans may have these restrictions. If you have Medicare Advantage, check your plan’s formulary.

What if I had a good response to a non-preferred brand in the past but now have new insurance with step therapy?

This is a strong basis for an exception request. Have your previous doctor send records documenting your successful treatment to your current doctor, who can submit this with the prior authorization request as justification to skip step therapy.

Are generic gel injection brands as good as name brands?

There are no true “generic” HA injections in the pharmaceutical sense (AB-rated generics). Lower-cost brands are still brand-name products, just with lower pricing. Clinical effectiveness varies by brand, molecular weight, formulation, and individual patient response. Some patients do fine with lower-cost brands; others get better results from premium brands.

Can I appeal step therapy requirements?

Yes. You can appeal through your insurance company’s internal process, request external medical review through your state, and in some states, there are step therapy override laws. Success depends on medical justification and your state’s regulations.

What’s the difference between “prior authorization” and “step therapy”?

Prior authorization means you need insurance approval before receiving treatment. Step therapy is a specific type of requirement within prior authorization that mandates trying one treatment before another. You might need prior authorization without step therapy (insurance just wants to review medical necessity), or you might have step therapy as part of the prior auth process.

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This article is for informational purposes only and does not constitute medical or insurance advice. Insurance policies vary significantly. Always verify coverage details with your specific insurance plan and consult with your healthcare provider about appropriate treatment options.

Last reviewed: January 2025

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