Dojolvi (triheptanoin) — United Healthcare
long-chain fatty acid oxidation disorders (LC-FAOD)
Initial criteria
- Diagnosis of long-chain fatty acid oxidation disorders (LC-FAOD)
- Disease has been molecularly confirmed (i.e., genetic testing)
- Patient is not receiving Dojolvi in combination with any other medium-chain triglyceride (MCT) products
Reauthorization criteria
- Documentation of positive clinical response to Dojolvi therapy
- Patient is not receiving Dojolvi in combination with any other medium-chain triglyceride (MCT) products
Approval duration
12 months