By Counterforce Health Team in Dojolvi (triheptanoin) —

Getting Dojolvi (Triheptanoin) Covered by Aetna CVS Health in New York: Complete Guide to Approval, Appeals & Forms

Answer Box: Quick Path to Coverage

Dojolvi (triheptanoin) is not on Aetna's 2024 formulary, requiring a formulary exception or prior authorization based on medical necessity. In New York, you have strong appeal rights through the state's external review system if initially denied.

Fastest approval path:

  1. Provider submits formulary exception request with genetic confirmation of LC-FAOD diagnosis
  2. Include evidence that Dojolvi is the only FDA-approved treatment for this condition
  3. If denied, file internal appeal within 65 days, then external review through NY Department of Financial Services within 4 months

Start today: Contact your prescriber to initiate the prior authorization process through Aetna's provider portal.

Table of Contents

Plan Types & Network Requirements

Your Aetna plan type affects how specialty drug coverage works:

HMO Plans:

  • Require in-network providers only
  • Need referrals to metabolic specialists
  • Specialty drugs covered only through network pharmacies
  • CVS Specialty is typically the preferred specialty pharmacy

PPO Plans:

  • Allow out-of-network providers at higher cost
  • No referrals needed for specialists
  • More flexibility in pharmacy choice, but CVS Specialty often preferred for specialty drugs

EPO Plans:

  • In-network providers required (except emergencies)
  • No referrals needed
  • Must use network specialty pharmacies
Note: All Aetna plan types in New York require prior authorization for non-formulary specialty drugs like Dojolvi.

Formulary Status & Coverage Criteria

Current Status: Dojolvi is not listed on Aetna's 2024 Standard Plan Formulary or Specialty Drug List, making it a non-formulary medication requiring special approval.

Medical Necessity Criteria

Based on Aetna's clinical policies, coverage requires:

Requirement Documentation Needed Source
Confirmed LC-FAOD diagnosis Genetic testing or biochemical confirmation Aetna Clinical Policy
FDA indication Prescription for approved LC-FAOD use FDA labeling
Specialist involvement Metabolic specialist, geneticist, or endocrinologist Aetna medical policy
Failure of alternatives Documentation of dietary management attempts Clinical notes

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Patient and provider
What: Insurance card, genetic test results, prior treatment history
Timeline: Before submission

2. Provider Submits Formulary Exception

Who: Prescribing physician
What: Complete prior authorization request via Aetna provider portal
Include:

  • Confirmed LC-FAOD diagnosis with genetic/biochemical testing
  • Statement that Dojolvi is the only FDA-approved treatment for LC-FAOD
  • Clinical rationale for medical necessity
  • Specialist consultation notes

Timeline: Submit immediately after diagnosis confirmation

3. CVS Specialty Enrollment

Who: Provider initiates, patient completes
What: CVS Specialty enrollment form
Timeline: Concurrent with PA submission

4. Aetna Review Process

Timeline: 30-45 days for standard review; 72 hours for expedited
Outcome: Approval, denial, or request for additional information

5. If Denied: Internal Appeal

Who: Patient or provider
What: Aetna Redetermination Request Form
Deadline: 65 days from denial notice
Timeline: 7 days for decision

6. If Still Denied: External Review

Who: Patient
What: NY State External Appeal Application
Where: NY Department of Financial Services
Deadline: 4 months from final internal denial
Timeline: 30 days (72 hours if expedited)

CVS Specialty Pharmacy Setup

Since Aetna typically routes specialty drugs through CVS Specialty, enrollment is crucial:

Provider Steps:

  1. Download condition-specific enrollment form from CVS Specialty website
  2. Complete all required fields with manual signature (stamps not accepted)
  3. Submit via fax to 1-800-323-2445 or call 1-800-237-2767

Patient Steps:

  1. Expect contact from CVS Specialty for delivery coordination
  2. Provide current address and contact preferences
  3. Discuss any needed support services or training
Tip: CVS Specialty will handle insurance verification and prior authorization coordination, but initial approval must come from Aetna first.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
"Not medically necessary" Emphasize FDA approval and lack of alternatives FDA labeling, specialist letter
"Experimental/investigational" Cite FDA approval for LC-FAOD FDA approval documentation
Missing genetic confirmation Provide molecular diagnostic results Genetic testing report
Concurrent MCT use Document discontinuation plan Provider attestation
Quantity/dosing concerns Reference FDA dosing guidelines Prescriber rationale

Appeals Process for New York Patients

New York offers robust patient protections for insurance denials:

Internal Appeal (Required First Step)

  • Form: Aetna Redetermination Request
  • Deadline: 65 days from denial
  • Methods: Online portal, mail, fax (1-855-633-7673), phone (1-866-235-5660)
  • Response time: 7 days standard, 72 hours expedited

External Review (After Internal Denial)

New York's external review system is particularly patient-friendly:

  • Authority: NY Department of Financial Services
  • Deadline: 4 months from final internal denial
  • Cost: Maximum $25 (waived for financial hardship)
  • Decision: Binding on insurer
  • Timeline: 30 days standard, 72 hours expedited for urgent drug needs

Key advantage: New York's external reviewers often overturn denials for rare disease treatments when FDA approval and medical necessity are clearly documented.

Clinician Corner: Medical Necessity Letter

When submitting the formulary exception, include these key elements:

Essential Components:

  • Patient diagnosis with ICD-10 codes
  • Genetic/biochemical confirmation of LC-FAOD
  • Statement: "Dojolvi is the only FDA-approved treatment for long-chain fatty acid oxidation disorders"
  • Prior dietary management attempts and outcomes
  • Clinical rationale for dosing (up to 35% of daily caloric intake)
  • Monitoring plan and treatment goals

Supporting Evidence:

Cost-Share Considerations

Typical Costs:

  • List price: ~$5,857-$6,365 per 500-mL bottle
  • Patient responsibility varies by plan design and tier placement

Financial Assistance:

  • Contact Ultragenyx patient support for manufacturer programs
  • Check eligibility for state pharmaceutical assistance programs
  • Consider foundation grants for rare disease treatments
Note: This is educational information only. Consult your plan documents for specific cost-sharing details.

When to Escalate

Contact NY Department of Financial Services if:

  • Aetna misses appeal deadlines
  • You need help with external review process
  • You believe your rights were violated

Resources:

FAQ

How long does Aetna prior authorization take for Dojolvi in New York?
Standard review takes 30-45 days. For urgent needs, request expedited review (72-hour response).

What if Dojolvi isn't on my Aetna formulary?
Submit a formulary exception request with medical necessity documentation. Non-formulary status doesn't mean automatic denial.

Can I get an expedited appeal in New York?
Yes, both Aetna's internal appeals and NY's external review offer expedited processes for urgent medical needs.

Does step therapy apply to Dojolvi?
Typically no, since it's the only FDA-approved treatment for LC-FAOD. Emphasize this in your appeal.

What if I already purchased Dojolvi out-of-pocket?
Include receipts in your appeal. If approved retroactively, you may receive reimbursement.

Can my doctor request a peer-to-peer review?
Yes, providers can request to speak directly with Aetna's medical director about the denial.

Getting insurance approval for rare disease treatments can feel overwhelming, but patients in New York have strong legal protections and multiple appeal options. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to craft point-by-point rebuttals. Our platform identifies the specific denial basis and drafts appeals aligned to each plan's own rules, pulling the right clinical evidence and operational details payers expect.

When facing a Dojolvi denial, remember that persistence often pays off. Many initial denials are overturned on appeal when the medical necessity is clearly documented and the appeal addresses the specific concerns raised in the denial letter. Counterforce Health's automated system can help streamline this process by generating appeals that meet Aetna's specific procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage criteria can change. Always verify current requirements with your specific plan and consult healthcare professionals for medical decisions. For personalized assistance with insurance appeals in New York, contact Community Health Advocates at 888-614-5400.

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