Prior Authorization : Services Requiring Prior Authorization

Dojolvi

Dojolvi requires clinical PA.

PA requests for Dojolvi must be completed, signed, and dated by the prescriber. PA requests for Dojolvi must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form. Clinical documentation supporting the use of Dojolvi must be submitted with the PA request.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for Dojolvi may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Dojolvi

Clinical criteria that must be documented for approval of a PA request for Dojolvi are all of the following:

• The member has a confirmed diagnosis of a long-chain fatty acid oxidation disorder.
• The member has a dietary assessment and a complete dietary treatment plan that includes all of the following:
  • The member's height, weight, and estimated total daily caloric intake
  • A copy of the prescription order for Dojolvi
  • The target daily dosage of Dojolvi as a percentage of the member's total daily caloric intake

Note: Dojolvi is prescribed in milliliters, and the recommended target daily dosage is up to 35 percent of the member's total daily caloric intake divided into at least four doses.

Supporting clinical information and a copy of the member's current medical records must be included in all PA requests. The supporting clinical information and the medical records must document the following:

• The member's medical condition being treated
• Details regarding previous medication use
• The member's current treatment plan