| Anthem Blue Cross (HMO, PPO, EPO) |
| Dojolvi (triheptanoin) |
| Drugs for Nutrition : Drugs for Nutrition |
- Long-chain fatty acid oxidation disorders (LC-FAOD):
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Available only through Specialty Pharmacy;
For fax form document click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- PA Applies
- Quantity Limit: 2 bottles per 30 day(s).
- Prior Authorization: Long-chain fatty acid oxidation disorders (LC-FAOD):
Duration: 1 year(s)
- Step Therapy: Long-chain fatty acid oxidation disorders (LC-FAOD):
ST Multiple Generics
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