Cholbam (cholic acid) — Highmark

Initial criteria

• age ≥ 3 weeks
• Diagnosis of peroxisomal disorder (ICD-10: E71.5) confirmed by one of the following: abnormal urinary bile acid detected by mass spectrometry (e.g., FAB-MS) OR other biochemical or genetic testing
• Cholbam used as adjunctive treatment
• Member exhibits at least one of the following manifestations: liver disease OR steatorrhea OR complications from decreased fat-soluble vitamin absorption

Reauthorization criteria

• Prescriber attests that the member has experienced positive clinical response to therapy

Approval duration

Initial: up to 3 months; Reauthorization: up to 12 months