By Counterforce Health Team in Dojolvi (triheptanoin) —

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

Answer Box: Getting Dojolvi Covered by Aetna CVS Health in Pennsylvania

Dojolvi (triheptanoin) requires prior authorization from Aetna CVS Health in Pennsylvania. The fastest path to approval: (1) Gather genetic confirmation of LC-FAOD diagnosis and specialist documentation, (2) Submit PA request through Aetna's provider portal with medical necessity letter, (3) Enroll with CVS Specialty Pharmacy simultaneously. If denied, Pennsylvania's new external review program has overturned 50% of appealed denials in 2024. Start with your metabolic specialist today to compile required documentation.

Table of Contents

Plan Types and Coverage Implications

Aetna CVS Health offers several plan types in Pennsylvania, each with different coverage rules for specialty medications like Dojolvi:

Commercial Plans (HMO/PPO/EPO): Most require prior authorization for Dojolvi, with CVS Specialty Pharmacy as the preferred dispensing location. PPO plans typically offer more flexibility in specialist selection, while HMO plans may require referrals to metabolic specialists.

Medicare Plans: Dojolvi is listed in Aetna's 2024 Medicare formularies for Pennsylvania as a specialty tier drug (Tier 5) requiring prior authorization and quantity limits.

Medicaid Plans: Coverage varies by specific Aetna Better Health Medicaid plan, but prior authorization is standard across all plans.

Note: Pennsylvania expanded Medicaid and established its own marketplace (Pennie), contributing to broader coverage options for rare disease treatments.

Formulary Status and Tier Placement

Current Status: Dojolvi is covered under Aetna CVS Health pharmacy plans in Pennsylvania as of 2024, but placement varies:

  • Specialty Tier (Tier 5): Highest cost-sharing tier
  • Prior Authorization Required: All plans require PA approval
  • Quantity Limits: Based on FDA-approved dosing (up to 35% of daily caloric intake)
  • Limited Access: Must be dispensed through CVS Specialty Pharmacy

Alternative Coverage: Since Dojolvi is the only FDA-approved treatment for LC-FAOD, formulary exceptions focus on medical necessity rather than trying alternative medications first.

Prior Authorization Requirements

Aetna requires comprehensive documentation for Dojolvi approval:

Core Requirements

  • Genetic/Biochemical Confirmation: Pathogenic mutations in LC-FAOD genes (CPT2, ACADVL, HADHA, or HADHB)
  • Specialist Involvement: Board-certified metabolic disease specialist, geneticist, or pediatric endocrinologist
  • ICD-10 Codes: E71.310, E71.318 with supporting lab results
  • Prior Treatment Documentation: Records of previous dietary therapy trials, including MCT oil outcomes
  • Medical Necessity Letter: Specialist must link diagnosis to FDA-approved Dojolvi indications

Dosing Requirements

  • Maximum 35% of daily caloric intake
  • Divided into ≥4 doses daily
  • Discontinuation of other MCT products documented
  • Nutritional assessment included

CVS Specialty Pharmacy Requirements

Enrollment Process: Patients must actively enroll with CVS Specialty Pharmacy, coordinated alongside prior authorization.

Required Documentation:

  • Completed enrollment forms
  • Insurance verification
  • Prescription from metabolic specialist
  • Prior authorization approval

Contact Information:

  • CVS Specialty: 1-800-237-2767
  • Enrollment typically takes 3-5 business days after PA approval

Cost-Share Basics

Specialty Tier Costs: As a Tier 5 medication, Dojolvi typically carries the highest copayment or coinsurance rates. Exact amounts vary by specific plan.

Financial Assistance:

  • Manufacturer Support: Ultragenyx offers patient assistance programs (verify current eligibility at dojolvi.com)
  • Foundation Grants: Various rare disease foundations provide medication assistance
  • State Programs: Pennsylvania has programs for residents with high medication costs
Important: This information is educational only. Consult your specific plan documents for exact cost-sharing amounts.

Step-by-Step: Fastest Path to Approval

Step 1: Confirm Diagnosis and Gather Documentation

Who: Patient with metabolic specialist
What: Genetic testing results, lab reports, clinical notes
Timeline: 1-2 weeks if testing already completed

Step 2: Schedule Specialist Consultation

Who: Patient
What: Board-certified metabolic specialist evaluation
Where: Find specialists through Aetna's provider directory
Timeline: 2-4 weeks depending on availability

Step 3: Document Prior Treatments

Who: Specialist and patient
What: Complete history of dietary management, MCT oil trials, outcomes
Timeline: 1 week for documentation compilation

Step 4: Submit Prior Authorization

Who: Specialist's office
What: Complete PA request via Aetna provider portal
Include: All required documentation, medical necessity letter
Timeline: 30-45 days for standard review, 72 hours for expedited

Step 5: Enroll with CVS Specialty

Who: Patient
What: Complete enrollment process
When: Simultaneously with PA submission
Timeline: 3-5 business days

Step 6: Follow Up

Who: Patient and specialist's office
What: Track PA status, respond to any requests for additional information
Timeline: Ongoing until approval

Step 7: Appeal if Denied

Who: Patient with specialist support
What: Internal appeal, then Pennsylvania external review if needed
Timeline: Internal appeals: 30-60 days; External review: 45 days

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing molecular confirmation Submit genetic testing results Pathogenic LC-FAOD mutations report
Concurrent MCT use Document discontinuation Specialist note confirming MCT cessation
Lack of specialist involvement Obtain metabolic specialist evaluation Board certification, consultation notes
Insufficient prior treatment history Compile complete treatment records Detailed history of dietary management attempts
Dosing concerns Provide nutritional assessment Caloric intake calculations, dosing rationale

Pennsylvania Appeals Process

Pennsylvania launched its Independent External Review Program in January 2024, providing a powerful tool for overturning insurance denials.

Internal Appeals (First Step)

  • Timeline: 30-60 days depending on plan type
  • Submission: Through Aetna member portal or by mail
  • Required: Final Adverse Benefit Determination letter

Pennsylvania External Review

  • Eligibility: After completing internal appeals
  • Success Rate: 50% of appeals overturned in 2024
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to consumers
  • Submission: Online at pa.gov/reviewmyclaim or call 1-877-881-6388

When to Request Expedited Review

  • Life-threatening condition
  • Serious jeopardy to health
  • Risk of permanent disability
  • Severe pain or suffering
From our advocates: "We've seen Pennsylvania's new external review process work particularly well for rare disease medications like Dojolvi when families submit comprehensive documentation upfront. The independent physicians reviewing these cases understand the limited treatment options for LC-FAOD and often overturn denials when the medical necessity is clearly established."

Required Documentation Checklist

Before Starting

  • Insurance card and policy information
  • Genetic testing results confirming LC-FAOD
  • Complete medical records from metabolic specialist
  • Documentation of prior dietary management attempts
  • Current prescription for Dojolvi
  • Contact information for CVS Specialty Pharmacy

For Prior Authorization

  • Medical necessity letter from specialist
  • ICD-10 diagnosis codes (E71.310, E71.318)
  • Genetic testing report with pathogenic mutations
  • Clinical notes from metabolic specialist
  • Prior treatment history and outcomes
  • Dosing calculations and nutritional assessment
  • Confirmation of MCT product discontinuation

For Appeals

  • Denial letter from Aetna
  • All original PA documentation
  • Additional clinical evidence
  • Peer-reviewed literature supporting use
  • Updated specialist evaluation
  • Patient impact statement

Counterforce Health: Streamlining Your Appeal Process

Counterforce Health specializes in 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 aligned with the insurer's own rules. For complex cases like Dojolvi appeals, Counterforce Health pulls the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaves them into appeals that meet procedural requirements while tracking deadlines and required documentation.

FAQ

How long does Aetna CVS Health prior authorization take in Pennsylvania? Standard PA decisions are issued within 30-45 days. Expedited reviews for urgent cases are completed within 72 hours when properly documented.

What if Dojolvi is non-formulary on my plan? Submit a formulary exception request along with your PA. Since Dojolvi is the only FDA-approved LC-FAOD treatment, exceptions are often granted with proper documentation.

Can I request an expedited appeal in Pennsylvania? Yes, both Aetna's internal process and Pennsylvania's external review offer expedited timelines (72 hours) when your health could be seriously jeopardized by delays.

Does step therapy apply to Dojolvi? Typically no. Aetna recognizes that Dojolvi is the only FDA-approved medication for LC-FAOD, though they may require documentation of prior dietary management attempts.

What happens if my appeal is denied? After exhausting Aetna's internal appeals, you can request Pennsylvania's external review within four months of your final denial letter. This independent process has overturned 50% of appeals in 2024.

How much does Dojolvi cost without insurance? Cash prices commonly range from $5,857–$6,365 per 500-mL bottle. Patient assistance programs may be available through the manufacturer.

Can I fill Dojolvi at my regular pharmacy? No, Aetna requires Dojolvi to be dispensed through CVS Specialty Pharmacy due to its specialty medication designation.

What if I need Dojolvi while my appeal is pending? Ask your specialist about requesting an emergency supply or temporary coverage while the appeal is processed. Pennsylvania's expedited external review (72 hours) may be appropriate for urgent situations.

Sources and Further Reading

For complex appeals requiring detailed clinical evidence and policy analysis, Counterforce Health provides specialized support in transforming denials into successful approvals through targeted, evidence-backed appeals.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult your healthcare provider and insurance plan documents for specific guidance. For assistance with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department's Office of Consumer Services.

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