Dojolvi (triheptanoin) — Highmark
long-chain fatty acid oxidation disorder (LC-FAOD)
Initial criteria
- Diagnosis of LC-FAOD
- Prescriber submits documentation that the member has a molecularly-confirmed gene mutation with one of the following: Carnitine Palmitoyl transferase type 1A (CPT1A) deficiency OR Carnitine-acylcarnitine translocase (CACT) deficiency OR Carnitine Palmitoyl transferase type 2 (CPT2) deficiency OR Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency OR Mitochondrial trifunctional protein (MTP) deficiency/trifunctional protein (TFP) deficiency OR Long-chain 3-Hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency
- Prescriber attests that the member is utilizing dietary management
- Prescriber attests that the member has experienced therapeutic failure, contraindication, or intolerance to commercially available medium chain triglyceride (MCT) products OR has experienced at least one significant clinical manifestation of LC-FAOD (e.g., rhabdomyolysis, cardiomyopathy, hypoglycemia)
- Prescriber attests that Dojolvi will not be used concomitantly with another MCT product
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
- Prescriber attests that Dojolvi will not be used concomitantly with another MCT product
Approval duration
12 months