Arthrosamid vs Durolane: aetna Coverage
Side-by-side comparison of aetna coverage for arthrosamid and durolane, including coverage status, prior authorization requirements, and estimated costs.
Coverage Comparison
How aetna covers each treatment option side by side.
| Factor | Arthrosamid | Durolane |
|---|---|---|
| Coverage Status | Not Covered | Covered |
| Prior Authorization | Not Required | Required |
| Estimated Cost | Varies by plan | Varies by plan |
| Requirements | None listed | 4 requirements |
Which Is Better Covered by aetna?
Durolane has better coverage under aetna. It is typically covered while Arthrosamid is not.
Overall Comparison Verdict
Durolane is the established, FDA-approved, insured option. Arthrosamid is a newer, longer-lasting option not yet FDA-approved in the US, requiring out-of-pocket payment. They use fundamentally different technologies.
Best for: Durolane for FDA-approved, Medicare-covered treatment; Arthrosamid for patients seeking longer-lasting relief who can pay out of pocket and access it.
See full comparisonCoverage Details
Arthrosamid
Durolane
Aetna coverage for Durolane requires prior authorization and documented conservative therapy failure.
Prior Authorization Requirements
Arthrosamid
No specific requirements listed
Durolane
- Documented knee osteoarthritis diagnosis
- Prior authorization required
- Failed conservative care (PT and NSAIDs minimum)
- In-network provider
Cost Comparison Under aetna
Arthrosamid
Durolane
Costs are estimates and may vary by specific plan, location, and provider. Contact aetna directly to verify your benefits.
Appeal Tips
If coverage is denied for either treatment, here are tips for appealing with aetna:
- Obtain prior authorization before every injection
- Document specific dates and outcomes of failed PT and NSAID therapy
- Request a peer-to-peer review between your doctor and the insurance medical reviewer
- File a formal appeal within the deadline stated in your denial letter
- Ask your provider to include X-ray or imaging evidence of joint space narrowing
Steps to Get Covered by aetna
Follow this process to get your treatment approved and minimize out-of-pocket costs.
Verify Your Benefits
Call aetna or log into your member portal to confirm your specific plan covers the treatment you're considering. Ask about deductibles, copays, and any limitations.
Get a Referral (If Required)
Some aetna plans require a referral from your primary care doctor to see a specialist. Check your plan type (HMO plans usually require referrals, PPO plans often don't).
Submit Prior Authorization
If prior authorization is required, your doctor's office will submit the request with clinical documentation including your diagnosis, imaging results, and records of previous treatments tried.
Wait for Approval
aetna typically processes prior authorization requests within 5-15 business days. Urgent requests may be expedited. Your doctor's office can follow up on the status.
Schedule Your Treatment
Once approved, schedule your treatment with an in-network provider to minimize out-of-pocket costs. Keep your approval reference number for your records.
Appeal If Denied
If denied, request the denial in writing and work with your doctor to submit an appeal with additional supporting documentation. Many denials are overturned on appeal.
Frequently Asked Questions
Does aetna cover Arthrosamid?
Arthrosamid is not typically covered by aetna. You may need to pay the full cost out of pocket (Varies by plan) or explore appeal options. Ask your doctor to submit a letter of medical necessity if they believe this treatment is appropriate for you.
Does aetna cover Durolane?
Yes, aetna typically covers Durolane. Prior authorization is required before treatment. The estimated out-of-pocket cost is Varies by plan. Verify your specific benefits with aetna before scheduling treatment.
Which has lower out-of-pocket costs with aetna: Arthrosamid or Durolane?
With aetna, the estimated cost for Arthrosamid is Varies by plan and for Durolane is Varies by plan. Since only Durolane is covered, it will likely have lower out-of-pocket costs. Always verify costs with your insurance before scheduling.
Do I need prior authorization for Arthrosamid or Durolane with aetna?
aetna requires prior authorization for Durolane but not for Arthrosamid. If you choose Durolane, expect a 5-15 business day approval process. Arthrosamid can usually proceed without pre-approval.
What if aetna denies coverage for my treatment?
If aetna denies coverage, you have the right to appeal. First, ask for the denial in writing with the specific reason. Then work with your doctor to submit an appeal with supporting clinical documentation, imaging results, and records of failed conservative treatments. Many initially denied claims are approved on appeal. You can also contact your state insurance commissioner if you believe the denial is unfair.
Quick Links
Verify Your Coverage
Coverage can vary by specific plan. Contact aetna directly to verify your benefits for both arthrosamid and durolane.
Arthrosamid vs Durolane with Other Insurance
Interested in This Treatment?
You've learned about Arthrosamid vs Durolane coverage with aetna. Here's how to move forward:
Take Assessment
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Check Coverage
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