By Counterforce Health Team in Dojolvi (triheptanoin) —

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

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

Dojolvi (triheptanoin) requires prior authorization from Aetna CVS Health and is not on the 2024 formulary, requiring a formulary exception. Essential requirements include genetic/biochemical LC-FAOD confirmation, specialist documentation, and proof that dietary management alone is inadequate. First step today: Contact your metabolic specialist to gather diagnostic test results and begin the prior authorization process through Aetna's provider portal while simultaneously enrolling with CVS Specialty Pharmacy. Standard review takes 30-45 days; expedited review available in 72 hours for urgent cases. If denied, Texas residents have 180 days to file internal appeals and can pursue independent external review through the Texas Department of Insurance.

Table of Contents

  1. Coverage Overview: How Aetna CVS Health Handles Dojolvi
  2. Medical Necessity Requirements
  3. Step-by-Step Approval Process
  4. Common Denial Reasons and Solutions
  5. Appeals Process in Texas
  6. Cost and Support Options
  7. Frequently Asked Questions
  8. Resources and Next Steps

Coverage Overview: How Aetna CVS Health Handles Dojolvi

Aetna CVS Health classifies Dojolvi as a specialty medication requiring both prior authorization and formulary exception approval. Since Dojolvi is not included on Aetna's 2024 formulary, your doctor must demonstrate medical necessity and show why no formulary alternatives are appropriate for your LC-FAOD diagnosis.

Plan Types and Coverage Rules

Commercial Plans (HMO/PPO/EPO): All require prior authorization with specialist involvement. HMO plans may have additional network restrictions requiring in-network metabolic specialists.

Medicare Advantage: Follow Medicare Part D guidelines with additional Aetna-specific requirements for specialty drugs.

Medicaid (Texas): Aetna Better Health of Texas follows state Medicaid guidelines but adds their own prior authorization layer.

Note: Self-funded employer plans (ERISA) may have different appeal rights and should verify their specific processes.

Medical Necessity Requirements

Essential Documentation Checklist

Diagnosis Confirmation:

  • Genetic testing results confirming LC-FAOD (specific gene variants in ACADVL, CPT1A, CPT2, HADHA, HADHB, or SLC25A20)
  • Biochemical confirmation via plasma acylcarnitine profiling
  • ICD-10 diagnostic codes for the specific LC-FAOD subtype

Specialist Involvement:

  • Documentation from a metabolic disease specialist, geneticist, or pediatric endocrinologist
  • Specialist consultation notes detailing diagnosis, treatment history, and Dojolvi necessity
  • Prescription written by or in consultation with the specialist

Prior Treatment Documentation:

  • Detailed history of dietary management attempts, including specific MCT oil trials
  • Documentation of inadequate response, intolerance, or contraindications to standard dietary therapy
  • Clinical endpoints showing why current management is insufficient

Dosing and Administration Requirements

Aetna requires documentation that the prescribed dose aligns with FDA-approved dosing guidelines:

  • Maximum 35% of total daily caloric intake
  • Divided into at least 4 doses per day
  • Mixed with food or formula
  • Discontinuation of other MCT products

Step-by-Step Approval Process

1. Gather Required Documentation (Patient/Clinic)

Timeline: 1-2 weeks
Action: Collect genetic test results, specialist notes, and prior treatment records
Submit to: Your prescribing physician

2. Submit Prior Authorization Request (Physician)

Timeline: 1-3 business days
Action: Complete Aetna's precertification form via provider portal
Include: All documentation from step 1 plus medical necessity letter

3. CVS Specialty Enrollment (Concurrent)

Timeline: 1-2 business days
Action: Enroll with CVS Specialty Pharmacy while PA is processing
Contact: CVS Specialty at 1-800-237-2767

4. Aetna Review Process

Timeline: 30-45 days standard, 72 hours expedited
Action: Aetna reviews submission and may request additional information
Expedited: Available if delay could jeopardize health (requires physician attestation)

5. Approval or Denial Decision

Timeline: Within review period
Action: Aetna issues coverage determination
Next steps: If approved, CVS Specialty ships medication; if denied, proceed to appeals

Clinician Corner: Medical Necessity Letter Template

Your medical necessity letter should address these key elements:

Patient Information:

  • Full name, DOB, member ID
  • Specific LC-FAOD diagnosis with ICD-10 code
  • Genetic test results confirming molecular diagnosis

Clinical Justification:

  • "Patient has molecularly confirmed [specific LC-FAOD] requiring specialized nutritional therapy"
  • "Standard dietary management including MCT oil has proven inadequate as evidenced by [specific clinical outcomes]"
  • "Dojolvi is the only FDA-approved therapy specifically indicated for LC-FAOD"

Supporting Evidence:

  • Reference FDA labeling for approved indication
  • Cite specific treatment failures or intolerances
  • Include monitoring plan and treatment goals

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing genetic confirmation Submit molecular testing results Lab reports showing specific gene variants
Lack of specialist involvement Obtain metabolic specialist consultation Specialist notes and prescription
Insufficient prior therapy trials Document dietary management attempts Clinical notes showing MCT oil trials and outcomes
Non-formulary status Request formulary exception Medical necessity letter explaining no suitable alternatives
Quantity limit exceeded Justify dose calculation Caloric intake calculations and FDA dosing guidelines

Appeals Process in Texas

Texas provides robust appeal rights for Aetna CVS Health members through both internal and external review processes.

Internal Appeals

Filing deadline: 180 days from denial notice
Review timeline: 30 days for pre-service appeals
Expedited timeline: 72 hours for urgent appeals
How to file: Submit via Aetna member portal or mail to address on denial letter

External Review (Independent Review Organization)

Filing deadline: 4 months from final internal denial
Review timeline: 20 days standard, 5 days expedited
Cost: No charge to patient (Aetna pays IRO fee)
Scope: Available for medical necessity denials and experimental/investigational determinations

Texas-Specific Resources

  • Texas Department of Insurance: 1-800-252-3439
  • IRO Information Line: 1-866-554-4926
  • Office of Public Insurance Counsel: 1-877-611-6742
From our advocates: We've seen successful Dojolvi appeals in Texas when families gathered comprehensive genetic testing results and obtained detailed specialist letters addressing each specific denial reason. The key was demonstrating that dietary management had been thoroughly attempted and documented before requesting Dojolvi coverage.

Cost and Support Options

Manufacturer Support Programs

UltraCare Program: Provides patient support services and may offer financial assistance for eligible patients. Contact: 1-833-587-2273

No-Cost Genetic Testing: Sponsored testing programs available for eligible patients with suspected LC-FAOD.

Pricing Information

Cash prices typically range from $5,857-$6,365 per 500-mL bottle. Counterforce Health helps patients navigate insurance denials and appeals to avoid out-of-pocket costs.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in Texas?
Standard review takes 30-45 days. Expedited review is available within 72 hours if your physician attests that delaying treatment could jeopardize your health.

What if Dojolvi is not on my formulary?
You'll need a formulary exception along with prior authorization. Your doctor must demonstrate medical necessity and show why no formulary alternatives are appropriate for LC-FAOD.

Can I request an expedited appeal in Texas?
Yes, if your physician provides written attestation that delaying treatment could seriously jeopardize your health. Expedited internal appeals must be decided within 72 hours.

What happens if my internal appeal is denied?
Texas residents can request an independent external review through the Texas Department of Insurance within 4 months of the final internal denial. This review is binding on Aetna.

Do I need a metabolic specialist to prescribe Dojolvi?
While not legally required, Aetna typically requires specialist involvement for approval. A metabolic disease specialist, geneticist, or pediatric endocrinologist should be involved in diagnosis and treatment planning.

How do I prove my LC-FAOD diagnosis to Aetna?
Submit both genetic testing results showing specific gene variants and biochemical confirmation via plasma acylcarnitine profiling. Sponsored testing programs may be available if you need genetic confirmation.

Resources and Next Steps

Immediate Actions

  1. Contact your metabolic specialist to gather all diagnostic documentation
  2. Request genetic testing if not already completed
  3. Begin prior authorization process through your physician
  4. Enroll with CVS Specialty Pharmacy concurrently

Texas-Specific Support

  • Texas Department of Insurance: www.tdi.texas.gov | 1-800-252-3439
  • Office of Public Insurance Counsel: Appeals guidance and consumer assistance

Professional Support

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for specialty medications like Dojolvi. Their platform analyzes denial letters and creates point-by-point rebuttals aligned with payer-specific requirements.

Key Forms and Documents

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with insurance appeals and coverage challenges, contact the Texas Department of Insurance at 1-800-252-3439.

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