By Counterforce Health Team in Dojolvi (triheptanoin) —

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

Quick Answer: Getting Dojolvi Covered by Aetna CVS Health in Virginia

Dojolvi (triheptanoin) requires prior authorization and formulary exception from Aetna CVS Health. You'll need molecular confirmation of long-chain fatty acid oxidation disorder (LC-FAOD), specialist prescription, and documentation that other MCT products have been discontinued. The fastest path: gather genetic testing results, have your metabolic specialist submit the PA request through Aetna's provider portal, and enroll with CVS Specialty Pharmacy. If denied, Virginia's external review process through the State Corporation Commission can overturn wrongful denials within 45 days.

First step today: Contact your prescribing specialist to confirm they have your genetic testing results and can initiate the prior authorization process.

Table of Contents

What This Guide Covers

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

Dojolvi is the only FDA-approved treatment for LC-FAOD, providing essential calories and fatty acids when the body can't properly break down long-chain fats. At around $5,857-$6,365 per 500-mL bottle, insurance coverage is crucial for most families.

Who this helps: Patients with confirmed LC-FAOD, parents of children with metabolic disorders, metabolic specialists, and advocacy organizations supporting rare disease patients.

Before You Start: Plan Verification

Confirm Your Coverage Type

First, verify exactly what type of Aetna plan you have:

  • Commercial Aetna plans: Follow standard prior authorization process
  • Self-funded employer plans: May have different requirements; check with HR
  • Medicaid managed by Aetna: Different formulary and approval criteria may apply
Tip: Check your insurance card for "CVS Health" branding, which indicates your prescription benefits are managed by CVS Caremark.

Verify Formulary Status

Dojolvi is typically non-formulary on Aetna plans, meaning it requires both prior authorization and a formulary exception. Your specialist can check this through Aetna's provider portal or by calling the pharmacy help line.

Specialty Pharmacy Requirements

Aetna requires Dojolvi to be dispensed through CVS Specialty Pharmacy. Your provider will need to coordinate enrollment during the PA process.

Gather Required Documentation

Essential Clinical Documentation

Diagnosis Confirmation:

  • Genetic testing showing pathogenic variants in LC-FAOD genes (ACADVL, CPT1A, CPT2, HADHA, HADHB, or SLC25A20)
  • Plasma acylcarnitine profile results
  • ICD-10 codes: E71.310 (Long chain/very long chain acyl CoA dehydrogenase deficiency) or E71.318 (Other disorders of fatty acid oxidation)

Prescriber Qualifications:

  • Board-certified metabolic disease specialist, geneticist, or pediatric endocrinologist
  • Documentation of specialist's experience with LC-FAOD management

Treatment History:

  • Previous trials of dietary therapy including MCT oil
  • Documentation of inadequate response or intolerance to standard treatments
  • Confirmation that other MCT products will be discontinued

Dosing Information:

  • Patient's total daily caloric intake (DCI)
  • Prescribed Dojolvi dose (≤35% of DCI, divided into ≥4 doses daily)
  • Body weight and nutritional assessment

Forms and Administrative Requirements

  • Aetna prior authorization form (available through provider portal)
  • CVS Specialty Pharmacy enrollment paperwork
  • Medical necessity letter from prescribing specialist

Submit the Prior Authorization Request

Step-by-Step Submission Process

Step 1: Provider Portal Submission Your specialist should submit the PA request through Aetna's provider portal. This is the fastest method and provides real-time tracking.

Step 2: Include All Required Documentation

  • Genetic testing results
  • Specialist consultation notes
  • Medical necessity letter addressing FDA indication and prior treatment failures
  • Dosing calculations based on patient's DCI

Step 3: CVS Specialty Pharmacy Coordination Your provider should simultaneously contact CVS Specialty Pharmacy at 1-800-237-2767 to begin enrollment.

Step 4: Submit Clean Request Packet Ensure all forms are complete, signed, and include:

  • Patient demographics and insurance information
  • Clear diagnosis with supporting lab results
  • Detailed treatment rationale
  • Dosing justification within FDA guidelines
Note: Incomplete submissions are a major cause of delays. Double-check all required fields before submitting.

Follow-Up and Tracking

When to Call for Updates

  • Day 3-5: Confirm Aetna received the complete submission
  • Day 10-15: Check status if no initial response
  • Day 25: Final status check before standard deadline

What to Ask During Follow-Up Calls

"I'm calling to check the status of prior authorization request [reference number] for Dojolvi for [patient name], DOB [date]. Can you tell me:

  • Has the request been assigned to a reviewer?
  • Are any additional documents needed?
  • What's the expected decision date?"

Documentation

Keep detailed records of all communications, including:

  • Reference numbers for PA requests
  • Names of representatives spoken to
  • Dates and times of all calls
  • Any additional information requested

Typical Timelines in Virginia

Standard Review Process

  • Aetna standard review: 30-45 days from complete submission
  • Expedited review: 72 hours (requires physician attestation of urgency)
  • CVS Specialty enrollment: 5-10 business days concurrent with PA review

Virginia-Specific Protections

Virginia insurance law requires timely processing of prior authorization requests. If Aetna exceeds standard timeframes without justification, you can file a complaint with the Virginia State Corporation Commission Bureau of Insurance.

If You're Asked for More Information

Common Additional Requests

Medical Necessity Clarification:

  • Provide more detailed explanation of LC-FAOD pathophysiology
  • Include FDA labeling information supporting Dojolvi use
  • Submit peer-reviewed studies on triheptanoin efficacy

Prior Treatment Documentation:

  • Detailed records of MCT oil trials and outcomes
  • Documentation of dietary modifications attempted
  • Specialist notes on treatment failures or intolerances

Response Strategy

Respond promptly to any additional information requests. Each day of delay extends your overall approval timeline. Work with your specialist to provide comprehensive responses that directly address Aetna's specific questions.

If Your Request is Denied

Understanding Denial Codes

Common Aetna denial reasons for Dojolvi:

  • Non-formulary: Drug not on preferred list
  • Medical necessity not established: Insufficient clinical documentation
  • Concurrent therapy: Other MCT products not discontinued
  • Dosing concerns: Prescribed dose exceeds FDA guidelines

First-Level Internal Appeal

You have 180 days from the denial date to file an internal appeal with Aetna. Include:

  • Copy of denial letter
  • Additional clinical documentation addressing denial reason
  • Updated medical necessity letter from specialist
  • Peer-reviewed literature supporting Dojolvi use in LC-FAOD

Peer-to-Peer Review Request

Your specialist can request a peer-to-peer discussion with Aetna's medical director. This often resolves denials when the reviewing physician better understands the rare disease and treatment rationale.

Virginia External Review Process

When External Review Applies

If Aetna upholds the denial after internal appeal, you can request external review through the Virginia State Corporation Commission Bureau of Insurance for denials based on:

  • Medical necessity
  • Experimental/investigational treatment determinations
  • Appropriateness of care

How to File External Review

Timeline: You have 120 days from Aetna's final denial to file external review.

Required Forms:

Submission:

  • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  • Fax: (804) 371-9915
  • Email: [email protected]

External Review Timeline

  • Standard review: 45 days from acceptance
  • Expedited review: 72 hours for urgent cases
  • Decision: Binding on both patient and insurer
From our advocates: "We've seen several LC-FAOD families succeed with Virginia's external review process by having their metabolic specialist provide a detailed letter explaining why Dojolvi is medically necessary and not experimental. The independent medical reviewers often have more specialized knowledge than the initial insurance reviewers."

Renewal and Reauthorization

Annual Reauthorization Requirements

Aetna typically approves Dojolvi for 12-month periods. For renewal, you'll need:

  • Updated specialist evaluation
  • Documentation of continued medical necessity
  • Evidence of clinical benefit (reduced hospitalizations, improved metabolic control)
  • Confirmation of ongoing specialist oversight

Calendar Reminders

Set reminders 60-90 days before your current authorization expires to begin the renewal process. This prevents treatment interruptions.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genetic confirmation Submit molecular testing results Pathogenic variant report
Concurrent MCT use Document discontinuation Specialist attestation
Non-formulary status Request formulary exception Medical necessity letter
Dosing exceeds guidelines Justify dose calculation DCI assessment, weight-based dosing
Lack of specialist oversight Confirm prescriber credentials Board certification documentation

Costs and Patient Support

Manufacturer Support Programs

Ultragenyx offers patient assistance through their Dojolvi support program. Eligibility varies based on insurance status and income.

Additional Resources

  • National Organization for Rare Disorders (NORD): Provides grants and advocacy support
  • Fatty Oxidation Disorders (FOD) Family Support Group: Peer support and insurance navigation assistance

At Counterforce Health, we specialize in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific criteria. For challenging cases like rare disease treatments, having the right documentation and appeal strategy can make the difference between denial and approval.

FAQ

Q: How long does Aetna CVS Health prior authorization take for Dojolvi in Virginia? A: Standard review takes 30-45 days. Expedited review (with physician attestation of urgency) is completed within 72 hours.

Q: What if Dojolvi is non-formulary on my Aetna plan? A: You'll need both prior authorization and a formulary exception. Your specialist must demonstrate medical necessity and that formulary alternatives are inappropriate.

Q: Can I request expedited appeal in Virginia? A: Yes, if your doctor certifies that waiting could seriously jeopardize your health. Virginia expedited external reviews are decided within 72 hours.

Q: Does step therapy apply to Dojolvi? A: Aetna may require documentation of failed trials with dietary MCT therapy before approving Dojolvi.

Q: What happens if my employer plan is self-funded? A: Self-funded ERISA plans may opt into Virginia's external review process. Check with your HR department or contact the Virginia Bureau of Insurance to verify eligibility.

Q: Can I use GoodRx or other discount programs for Dojolvi? A: Discount programs typically don't apply to specialty medications like Dojolvi. Focus on insurance coverage and manufacturer assistance programs.

Quick Reference Checklist

Before Starting:

  • Verify Aetna plan type and CVS Caremark coverage
  • Confirm Dojolvi formulary status
  • Identify prescribing specialist credentials

Documentation Needed:

  • Genetic testing results showing LC-FAOD
  • ICD-10 codes (E71.310 or E71.318)
  • Prior MCT therapy records
  • Daily caloric intake assessment
  • Medical necessity letter

Submission Steps:

  • Provider submits PA through Aetna portal
  • Enroll with CVS Specialty Pharmacy
  • Track reference numbers
  • Follow up at regular intervals

If Denied:

  • File internal appeal within 180 days
  • Request peer-to-peer review
  • Consider Virginia external review within 120 days

Contact Information:

  • Aetna Provider Services: Check current number on provider portal
  • CVS Specialty Pharmacy: 1-800-237-2767
  • Virginia Bureau of Insurance: 1-877-310-6560
  • External Review Email: [email protected]

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For additional help with insurance appeals and coverage issues in Virginia, contact the Virginia State Corporation Commission Bureau of Insurance at 1-877-310-6560.

Whether you're facing an initial denial or need help navigating the complex prior authorization process, Counterforce Health provides the tools and expertise to turn insurance obstacles into approval opportunities, helping ensure patients get access to the specialized treatments they need.

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