By Counterforce Health Team in Dojolvi (triheptanoin) —

Get Dojolvi (Triheptanoin) Covered by Humana in Michigan: Complete Appeals Guide with Forms and Timelines

Answer Box: Quick Start Guide

Getting Dojolvi (triheptanoin) covered by Humana in Michigan requires molecular confirmation of your long-chain fatty acid oxidation disorder and prior authorization. Start today by gathering genetic test results and having your specialist submit a medical necessity letter through Humana's provider portal. If denied, you have 65 days to appeal (Medicare plans) or can file for Michigan's external review within 127 days. For urgent cases, expedited appeals are decided within 72 hours with physician support. Michigan's Department of Insurance and Financial Services provides strong consumer protections beyond federal requirements.

Table of Contents

Why Michigan State Rules Matter

Michigan's insurance regulations provide additional protections beyond federal requirements, especially for rare disease medications like Dojolvi. The state's Patient's Right to Independent Review Act gives you 127 days to file for external review—longer than the federal 120-day standard—and expedited reviews are decided within 72 hours when medically urgent.

Important distinction: If you have Humana Medicare Advantage, federal Medicare appeals rules apply instead of Michigan's PRIRA. However, Michigan's Department of Insurance and Financial Services (DIFS) still provides consumer assistance and can help navigate the process.

For commercial Humana plans, Michigan's full external review protections apply, giving you an independent medical panel's binding decision if Humana denies coverage.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Humana plans Humana Drug Lists Humana Policy
Molecular Confirmation Genetic testing proving LC-FAOD diagnosis Lab results from genetic counselor/specialist Prime Therapeutics PA Criteria
Formulary Status Check your specific plan's covered drugs Humana Medicare Drug List Plan Documents
Specialist Prescription Must be prescribed by metabolic specialist Provider network directory Humana Requirements
Step Therapy May require trying alternatives first Prior authorization form Plan Policy

Fastest Path to Approval: Step-by-Step

1. Confirm Your Diagnosis Documentation

Who does it: Patient with specialist
Document needed: Molecular/genetic test results confirming LC-FAOD
Timeline: Gather immediately if available
Source: Prime Therapeutics requires genetic confirmation

2. Check Humana's Current Formulary

Who does it: Patient or clinic staff
How to submit: Online drug lookup tool
Timeline: 5-10 minutes
Source: Humana Drug List Search

3. Gather Prior Therapy Documentation

Who does it: Specialist's office
Documents needed: Records of MCT oil trials, dietary therapy attempts, hospitalizations
Timeline: 1-2 business days
Note: Document why standard therapies were insufficient

4. Submit Prior Authorization Request

Who does it: Prescribing physician
How to submit: Humana provider portal or fax
Expected timeline: 72 hours standard, 24 hours expedited
Source: CMS Medicare Part D Exception Timelines

5. Follow Up on Decision

Who does it: Patient or clinic
Timeline: Contact Humana if no response within required timeframe
Next step: If denied, proceed to appeals process

Turnaround Standards and Timelines

Michigan and federal regulations set strict timelines for Humana's responses:

Initial Prior Authorization:

  • Standard requests: 72 hours (Medicare Part D)
  • Expedited requests: 24 hours (when delay could harm health)
  • Commercial plans: Varies by contract, typically 2-5 business days

Appeals Timeline:

  • Medicare Advantage/Part D: 65 days from denial to file appeal
  • Commercial plans: Follow internal appeal first, then 127 days for Michigan external review
  • Expedited appeals: 72 hours for urgent medical situations
Tip: Calendar days, not business days, apply to most deadlines. Mark your calendar immediately upon receiving any denial.

Step Therapy Protections and Medical Exceptions

Michigan law and Humana policies allow medical exceptions to step therapy requirements when:

  • Clinical contraindication: Standard treatments are medically inappropriate
  • Prior failure: You've already tried and failed required alternatives
  • Urgent need: Delay would cause serious harm

Documentation phrases that help:

  • "Patient has molecular confirmation of [specific LC-FAOD type]"
  • "Standard MCT therapy resulted in [specific adverse outcomes]"
  • "Dojolvi is the only FDA-approved treatment for this condition"
  • "Delay in treatment increases risk of metabolic decompensation"

Continuity of Care During Transitions

Michigan provides strong continuity protections, especially during plan changes:

Medicaid Transitions: Up to 180 days of continued coverage for ongoing specialty medications when switching between Michigan Medicaid plans.

Commercial Plans: While Michigan doesn't mandate specific continuity periods for employer plans, you can:

  • Request emergency supplies while prior authorization is pending
  • File expedited appeals if therapy interruption poses health risks
  • Use Michigan's external review process for binding decisions

For ongoing Dojolvi therapy: Contact both your old and new plan immediately when transitioning to prevent gaps in coverage.

Appeals Playbook for Michigan

Internal Appeals (Required First Step)

Medicare Plans:

  • Deadline: 65 days from denial
  • How to file: Humana member portal or written request
  • Required documents: Denial letter, medical records, physician letter of medical necessity

Commercial Plans:

  • Deadline: Varies (typically 180 days)
  • Process: Follow plan's internal grievance procedure first

Michigan External Review (Commercial Plans Only)

When eligible: After completing internal appeals or if Humana doesn't respond timely
Deadline: 127 days from final internal denial
How to file: DIFS External Review Request
Cost: Free to patients
Timeline: 60 days standard, 72 hours expedited

Required for expedited review: Physician letter stating delay would "seriously jeopardize life, health, or ability to regain maximum function"

Medicare Appeals (Medicare Advantage/Part D)

Level 1: Redetermination (7 days standard, 72 hours expedited)
Level 2: Independent Review Entity
Level 3: Administrative Law Judge Hearing
Levels 4-5: Medicare Appeals Council and Federal Court

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Submit specialist letter with genetic test results Molecular confirmation per Prime Therapeutics criteria
"Non-formulary drug" Request formulary exception Medical necessity letter explaining why alternatives failed
"Quantity limits exceeded" Document appropriate dosing for patient's weight/caloric needs FDA label dosing guidelines, dietitian consultation
"Concurrent MCT use" Confirm discontinuation of other MCT products Updated medication list, pharmacy records
"Insufficient prior therapy" Document failed dietary management attempts Hospital records, nutrition consultation notes

Scripts and Templates

Patient Phone Script for Humana

"Hello, I'm calling about prior authorization for Dojolvi, generic name triheptanoin, for my long-chain fatty acid oxidation disorder. I have genetic confirmation of my diagnosis and my specialist has submitted the medical necessity documentation. Can you provide the status and reference number for tracking?"

Clinic Staff Peer-to-Peer Request

"We're requesting a peer-to-peer review for Dojolvi prior authorization. Our patient has molecular confirmation of [specific LC-FAOD] and has failed standard dietary therapy. This is the only FDA-approved treatment for their condition. When can we schedule the review with your medical director?"

Costs and Financial Assistance

Cash prices for Dojolvi range from $5,857-$6,365 per 500-mL bottle, making insurance approval essential.

Financial assistance options:

  • Ultragenyx Patient Support: Contact manufacturer at (844) 887-4337
  • Michigan Medicaid: May cover if commercial insurance denies
  • Rare disease foundations: National Organization for Rare Disorders (NORD) patient assistance programs

When working with Counterforce Health, patients and clinicians get targeted support for turning insurance denials into successful appeals. The platform helps identify specific denial reasons and drafts evidence-backed rebuttals aligned with each payer's requirements, potentially saving months of back-and-forth with insurers.

Frequently Asked Questions

Q: How long does Humana prior authorization take in Michigan?
A: Standard requests must be decided within 72 hours for Medicare Part D plans, 24 hours for expedited requests when delay could harm your health.

Q: What if Dojolvi is non-formulary on my Humana plan?
A: You can request a formulary exception with medical necessity documentation. If denied, appeal through Humana's internal process, then Michigan's external review if you have a commercial plan.

Q: Can I request an expedited appeal in Michigan?
A: Yes. Michigan offers 72-hour expedited external reviews when your physician certifies that delay would seriously jeopardize your health. Medicare plans also have expedited appeal options.

Q: Does step therapy apply if I failed treatments outside Michigan?
A: Yes, prior therapy failures from any location count toward step therapy requirements. Gather documentation from all previous providers.

Q: What's the difference between Medicare and commercial plan appeals in Michigan?
A: Medicare plans follow federal appeals procedures with 5 levels of review. Commercial plans can use Michigan's external review system through DIFS, which provides binding decisions from independent medical experts.

Q: Who can help me navigate the appeals process?
A: Contact Michigan DIFS at (877) 999-6442 for consumer assistance. Your specialist's office should also help coordinate appeals and provide necessary documentation.

Q: What happens if I miss an appeal deadline?
A: You may lose your right to appeal that specific denial. However, you can always resubmit a new prior authorization request with additional documentation.

Q: How do I prove medical necessity for Dojolvi?
A: Submit genetic test results confirming LC-FAOD diagnosis, documentation of failed dietary therapies, specialist letters explaining why Dojolvi is essential, and evidence of metabolic instability without treatment.

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For additional help with Michigan insurance appeals, contact the Department of Insurance and Financial Services at (877) 999-6442 or visit their external review page.

About Coverage Appeals: Counterforce Health specializes in helping patients, clinicians, and pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify specific denial reasons, then drafts point-by-point rebuttals with the right medical evidence and citations to maximize approval chances.

Sources & Further Reading

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