By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by Aetna CVS Health in New Jersey: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Dojolvi Covered by Aetna CVS Health in New Jersey

Dojolvi (triheptanoin) is non-formulary on Aetna CVS Health plans and requires both prior authorization and formulary exception. You'll need molecular confirmation of LC-FAOD, documented MCT oil failure/intolerance, and specialist prescriber. Submit through Aetna's provider portal while simultaneously enrolling with CVS Specialty Pharmacy. Standard review takes 30-45 days; expedited review available within 72 hours for urgent cases. If denied, New Jersey's IHCAP external review program offers binding decisions within 45 days.

First step today: Contact your metabolic specialist to gather genetic testing results, treatment history, and begin the dual PA/specialty pharmacy enrollment process.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in New Jersey
  7. If You're Asked for More Information
  8. If Your Request is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps patients with long-chain fatty acid oxidation disorders (LC-FAOD) and their healthcare teams navigate Aetna CVS Health's prior authorization process for Dojolvi (triheptanoin) in New Jersey. We'll walk through every step from initial documentation to appeals, including New Jersey's specific external review rights.

Who this helps:

  • Patients with confirmed LC-FAOD needing Dojolvi coverage
  • Parents and caregivers managing the approval process
  • Clinicians submitting prior authorizations
  • Anyone facing an Aetna CVS Health denial for Dojolvi

Expected outcomes: With proper documentation, most medically appropriate Dojolvi requests receive approval. New Jersey's robust external review system provides additional protection—about half of external appeals favor patients nationwide.

Before You Start: Verify Your Coverage

Confirm Your Plan Type

Commercial Aetna Plans: Follow the process outlined in this guide. You have 180 days to appeal denials and can access New Jersey's IHCAP external review.

Medicare Advantage: Different timelines apply (60 days for standard appeals). Contact Aetna Medicare customer service at 1-833-859-6031.

Medicaid (Aetna Better Health NJ): Medicaid-specific prior authorization forms and timelines. Contact member services at 1-855-232-3596.

Check Formulary Status

Dojolvi is classified as a specialty, non-formulary medication on most Aetna CVS Health plans. This means you need both:

  • Prior authorization approval
  • Formulary exception approval
  • CVS Specialty Pharmacy enrollment
Note: Retail pharmacies cannot dispense Dojolvi—it must come through CVS Specialty Pharmacy once approved.

Gather Required Documentation

Essential Medical Records

Genetic Confirmation (Required)

  • Molecular testing showing pathogenic variants in LC-FAOD genes
  • Common genes: ACADVL, CPT1A, CPT2, HADHA, HADHB, SLC25A20
  • Include laboratory report with specific mutations identified

Diagnosis Documentation

  • ICD-10 codes: E71.310 (VLCAD/LCAD deficiency) or E71.318 (other LC-FAOD)
  • Clinical notes showing LC-FAOD symptoms and complications
  • Evidence of at least one hospitalization or ER visit within past year due to LC-FAOD

Treatment History

  • Documentation of MCT oil trial (minimum 90 days unless contraindicated)
  • Specific adverse effects or inadequate response to MCT oil
  • Date MCT oil was discontinued (required before starting Dojolvi)
  • Other dietary therapies attempted and outcomes

Prescriber Requirements

Dojolvi must be prescribed by a board-certified:

  • Metabolic disease specialist
  • Geneticist
  • Pediatric endocrinologist

Include the prescriber's credentials and experience with LC-FAOD in your submission.

Dosing and Nutrition Plan

Required Elements:

  • Patient's total daily caloric intake
  • Prescribed Dojolvi dose (not to exceed 35% of daily calories)
  • Titration schedule (typically 5% increments every 2-3 days)
  • Plan divided into at least 4 doses per day
  • Confirmation that pancreatic insufficiency has been ruled out

Submit Your Prior Authorization Request

Dual Submission Process

Step 1: Aetna Prior Authorization Submit through Aetna's provider portal or via fax. Include:

  • Completed prior authorization form
  • All medical documentation listed above
  • Detailed medical necessity letter from specialist

Step 2: CVS Specialty Pharmacy Enrollment Simultaneously contact CVS Specialty at 1-800-237-2767 to begin enrollment. Both processes must be completed for coverage.

Medical Necessity Letter Checklist

Your specialist should address:

  • Confirmed LC-FAOD diagnosis with genetic evidence
  • Clinical complications and hospitalizations
  • MCT oil trial failure or contraindication with specific dates
  • Why Dojolvi is medically necessary vs. alternatives
  • Dosing rationale within FDA guidelines
  • Monitoring plan and safety considerations

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific requirements.

Follow-Up and Tracking

When to Call Aetna CVS Health

Week 1: Confirm receipt of your submission Week 3: Check status if no update received
Week 5: Escalate if approaching 45-day deadline

Sample Phone Script

"I'm calling to check the status of prior authorization request [reference number] for Dojolvi submitted on [date]. The patient has confirmed LC-FAOD and needs this medication for a life-threatening condition. Can you provide an update on timing and any additional information needed?"

Document Everything

Keep records of:

  • Submission dates and confirmation numbers
  • Phone call dates, representatives spoken with, and outcomes
  • Any additional information requests
  • Decision dates and reference numbers

Typical Timelines in New Jersey

Review Type Aetna Timeline New Jersey Requirement
Standard PA 30-45 days Must meet federal standards
Expedited PA 72 hours Available for urgent medical need
Internal Appeal 30-45 days Patient has 180 days to file
External Review (IHCAP) 45 days Patient has 4 months to file
Expedited External Review 48 hours Available for urgent cases
Tip: If Aetna fails to meet these timelines, your appeal may be automatically approved under federal regulations (29 CFR 2560.503-1).

If You're Asked for More Information

Common Additional Requests

"Need more genetic testing details"

  • Provide full laboratory report with specific mutations
  • Include interpretation of pathogenicity
  • Add any additional confirmatory testing

"Insufficient evidence of MCT oil failure"

  • Submit detailed treatment logs showing doses, duration, and outcomes
  • Include clinical notes documenting adverse effects or inadequate response
  • Provide exact discontinuation date

"Need specialist consultation notes"

  • Ensure notes clearly state LC-FAOD diagnosis and complications
  • Include rationale for Dojolvi over other treatments
  • Add monitoring plan and safety considerations

If Your Request is Denied

Understanding Your Denial

Common denial reasons for Dojolvi:

  • Missing molecular confirmation
  • Concurrent MCT use not discontinued
  • Lack of specialist prescriber
  • Insufficient evidence of medical necessity
  • Non-formulary status without exception request

New Jersey Appeals Process

Internal Appeal (First Step)

  • File within 180 days of denial
  • Submit additional documentation addressing denial reason
  • Request peer-to-peer review with specialist if available
  • Decision within 30-45 days (72 hours if expedited)

External Review Through IHCAP If internal appeal fails:

  • File within 4 months of final internal denial
  • Contact Maximus Federal Services: 888-866-6205
  • Mail to: Maximus Federal Services, Attn: New Jersey IHCAP, 3750 Monroe Avenue, Suite 702, Pittsford, NY 14534
  • Decision within 45 days (binding on Aetna)
From our advocates: "We've seen several LC-FAOD cases where initial denials were overturned at the external review level in New Jersey. The key was providing comprehensive genetic testing results and clear documentation of MCT oil discontinuation with specific dates. IHCAP reviewers appreciate thorough, well-organized submissions that directly address the original denial reasons."

Need help with appeals? Counterforce Health specializes in turning insurance denials into successful appeals by identifying specific denial reasons and crafting targeted responses with the right medical evidence and procedural requirements.

New Jersey Consumer Resources

DOBI Consumer Hotline: 1-800-446-7467
IHCAP Information: 1-888-393-1062
NJ Managed Care Ombudsman: Available for additional support with complex cases

Renewal and Re-Authorization

When to Start Renewal Process

Begin renewal 60-90 days before your current authorization expires (typically 12 months from approval).

Renewal Documentation

Include:

  • Updated clinical notes showing continued medical necessity
  • Current lab values and monitoring results
  • Evidence of therapeutic benefit from Dojolvi
  • Confirmation that alternative treatments remain inappropriate
  • Updated dosing if changed

Quick Reference Checklist

Before Submitting

  • Genetic testing report with specific LC-FAOD mutations
  • ICD-10 diagnosis code (E71.310 or E71.318)
  • MCT oil trial documentation and discontinuation date
  • Specialist prescriber credentials verified
  • Dosing plan within FDA guidelines (≤35% daily calories)
  • CVS Specialty Pharmacy enrollment initiated

After Submission

  • Confirmation numbers documented
  • Follow-up calls scheduled
  • Appeal deadlines calendared (180 days internal, 4 months external)
  • Additional information requests tracked
  • Decision documentation filed

If Denied

  • Denial reason identified
  • Internal appeal filed within 180 days
  • Peer-to-peer review requested
  • External review prepared if needed
  • IHCAP contact information ready

Costs and Financial Assistance

Dojolvi Cash Pricing: Approximately $5,857-$6,365 per 500-mL bottle Manufacturer Support: Ultragenyx offers patient assistance programs—contact 1-844-687-4872 Foundation Grants: Organizations like NORD and HealthWell Foundation may provide assistance for rare disease treatments

FAQ

How long does Aetna CVS Health prior authorization take in New Jersey? Standard review: 30-45 days. Expedited review: 72 hours for urgent medical situations.

What if Dojolvi is non-formulary on my plan? You'll need both prior authorization and formulary exception approval. Both are typically processed together.

Can I request an expedited appeal in New Jersey? Yes, if waiting would seriously jeopardize your health. Both Aetna (72 hours) and IHCAP (48 hours) offer expedited reviews.

Does step therapy apply if I've tried MCT oil outside New Jersey? Yes, document the trial regardless of where it occurred. Include treatment records and outcomes.

What happens if I switch Aetna plans during treatment? You may need a new prior authorization. Contact member services immediately to avoid treatment interruption.

Can my doctor file an external appeal on my behalf? Yes, New Jersey allows providers to file IHCAP appeals with patient consent.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage decisions depend on individual circumstances, plan details, and medical necessity. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For questions about New Jersey insurance regulations, contact the Department of Banking and Insurance at 1-800-446-7467.

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