Cholbam (cholic acid) — CareFirst (Caremark)

Initial criteria

• Diagnosis confirmed by mass spectrometry or other biochemical testing, or by genetic testing
• Member exhibits manifestations of liver disease (elevated transaminases, elevated bilirubin, or presence of cholestasis)

Reauthorization criteria

• Member is currently receiving the requested medication through a paid pharmacy or medical benefit
• Member has achieved and maintained improvement in liver function from baseline (reduced transaminases, reduced bilirubin, no evidence of cholestasis on liver biopsy)

Approval duration

Initial: 6 months; Reauthorization: 12 months