Dojolvi (triheptanoin) — Blue Cross Blue Shield of Alabama

Other indication supported in compendia for triheptanoin

Initial criteria

- The patient has ONE of the following:
• Diagnosis of long-chain fatty acid oxidation disorder (LCFAOD) AND ALL of the following:
- Diagnosis confirmed by at least TWO of the following:
• Disease-specific elevations of acylcarnitines on a newborn blood spot or in plasma
• Enzyme activity assay (in cultured fibroblasts or lymphocytes) demonstrating deficiency of an enzyme associated with LCFAODs
• Genetic testing demonstrating pathogenic mutation in a gene associated with LCFAODs
- The patient had symptomatic LCFAOD prior to therapy with the requested agent
- The patient will not be concurrently using another medium chain triglyceride product
- The patient will not be using the requested agent for more than 35% of the patient’s total prescribed daily caloric intake
OR
• Another FDA labeled indication for the requested agent and route of administration
OR
• Another indication that is supported in compendia for the requested agent and route of administration
AND
- The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or has consulted with a specialist
AND
- The patient does NOT have any FDA labeled contraindications to the requested agent

- The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
- The patient has had clinical benefit with the requested agent
- If the patient has a diagnosis of LCFAOD, BOTH of the following:
• The patient will not be concurrently using another medium chain triglyceride product
• The patient will not be using the requested agent for more than 35% of the patient's total prescribed daily caloric intake
- The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or has consulted with a specialist
- The patient does NOT have any FDA labeled contraindications to the requested agent

12 months