How to Get Dojolvi (Triheptanoin) Covered by Aetna CVS Health in Washington: Complete Coding, Prior Auth & Appeals Guide
Answer Box: Getting Dojolvi Covered by Aetna CVS Health in Washington
Fastest path to approval: Submit a specialty drug prior authorization request with molecular LC-FAOD confirmation (ICD-10 E71.318), discontinuation of MCT products, and metabolic specialist oversight. Use HCPCS J8499 with correct NDC for billing. If denied, Washington residents have strong external review rights through certified Independent Review Organizations (IROs). Start today: Call Aetna at 1-855-240-0535 to verify current formulary status and obtain the specialty drug PA form.
Table of Contents
- Coding Basics: Medical vs. Pharmacy Benefit
- ICD-10 Mapping for LC-FAOD
- Product Coding: HCPCS, NDC, and Units
- Clean Prior Authorization Request
- Common Billing Pitfalls
- Verification with Aetna CVS Health
- Appeals Process in Washington
- Cost Assistance Options
- Quick Audit Checklist
- FAQ
Coding Basics: Medical vs. Pharmacy Benefit
Dojolvi (triheptanoin) is typically covered under the pharmacy benefit as a specialty oral medication, not as a medical benefit infusion. This distinction matters because:
- Pharmacy benefit: Requires specialty drug prior authorization through CVS Caremark
- Medical benefit: Would use different forms and review processes
- Site of care: Home use, not facility-based administration
Tip: Always verify benefit category with Aetna before submitting requests, as some rare disease therapies can be covered under either pathway depending on the specific plan design.
ICD-10 Mapping for LC-FAOD
The primary diagnosis code for long-chain fatty acid oxidation disorders is:
- E71.318: Other disorders of fatty acid oxidation, specified
- E71.30: Disorder of fatty acid oxidation, unspecified (less preferred)
- E71.312: Very long chain acyl CoA dehydrogenase deficiency (if specifically confirmed)
Documentation Requirements
Your medical records must include:
- Molecular confirmation: Genetic test results showing pathogenic variants in LC-FAOD genes
- Clinical presentation: Symptoms consistent with fatty acid oxidation disorder
- Specialist involvement: Notes from metabolic or genetic specialist
- Prior treatments: Documentation of dietary management attempts
According to FDA labeling, Dojolvi is indicated for "molecularly confirmed long-chain fatty acid oxidation disorders."
Product Coding: HCPCS, NDC, and Units
HCPCS J-Code
Dojolvi does not have a unique HCPCS J-code. Use:
- J8499: Prescription drug, oral, non-chemotherapeutic, NOS (not otherwise specified)
NDC Requirements
- Must include valid 11-digit NDC from Ultragenyx
- Check current product packaging for most recent NDC
- NDC must match the actual dispensed product
Dosing and Units
Dojolvi is dosed as a percentage of Daily Caloric Intake (DCI):
- Target dose: Up to 35% of DCI
- Calculation: Total daily dose (mL) = (DCI × Target %) ÷ 8.3 kcal/mL
- Administration: Divided into at least 4 doses daily
- Units: Always prescribe and bill in milliliters (mL), never grams
Example calculation: For a patient with 1,200 kcal DCI targeting 35%: 1,200 × 0.35 ÷ 8.3 = 51 mL daily (approximately 13 mL per dose, four times daily)
Clean Prior Authorization Request
Required Documentation Checklist
Patient Information:
- Full name, date of birth, member ID
- Prescribing physician and NPI
- Diagnosis with ICD-10 code (E71.318)
Clinical Justification:
- Molecular genetic testing results confirming LC-FAOD
- Current symptoms and functional limitations
- Prior treatment history, including MCT oil trials
- Specialist consultation notes
- Planned dosing regimen with DCI calculations
Regulatory Requirements:
- FDA indication confirmation
- Contraindications to alternative therapies
- Plan for monitoring and follow-up
Submission Process
Aetna CVS Health Specialty Drug Prior Authorization:
- Fax: 1-888-267-3277
- Online: Availity provider portal
- Phone: 1-855-240-0535 (Mon-Fri, 8 AM-6 PM CT)
- Form: Specialty Drug Prior Authorization Request Form
Common Billing Pitfalls
| Pitfall | Impact | Solution |
|---|---|---|
| Prescribing in grams instead of mL | Dosing confusion, billing errors | Always use mL; 1 mL = 8.3 kcal |
| Missing molecular confirmation | Automatic denial | Include genetic test results |
| Concurrent MCT oil use | Policy violation | Document MCT discontinuation |
| Wrong J-code | Claim rejection | Use J8499 with NDC |
| Missing specialist oversight | Medical necessity failure | Include metabolic specialist notes |
Note: According to Prime Therapeutics coverage policy, common denial reasons include "missing molecular/biochemical confirmation" and "concurrent MCT use not discontinued."
Verification with Aetna CVS Health
Before submitting your request:
- Check formulary status: Review the Aetna Specialty Drug List
- Verify PA requirements: Confirm current prior authorization criteria
- Review member benefits: Check specialty drug cost-sharing (typically Tier 4)
- Confirm submission method: Verify preferred submission pathway (fax vs. portal)
Appeals Process in Washington
Washington state provides robust appeal rights for insurance denials, including a strong external review process.
Internal Appeals (Required First Step)
- Timeline: File within 180 days of denial
- Process: Submit through Aetna member portal or by mail
- Documentation: Include all supporting clinical evidence
- Decision timeframe: Standard 30 days, expedited 72 hours
External Review (Independent Review Organization)
If internal appeals fail, Washington residents can request external review:
- Eligibility: Available after final internal denial
- Filing: Through your health plan, which notifies the Office of the Insurance Commissioner
- Timeline: 180 days from final internal denial to request
- Decision timeframe: 20 days for fully-insured plans, 45 days for self-insured
- Expedited: 72 hours if delay poses serious health risk
- Authority: IRO can overturn insurer decisions deemed unreasonable
Washington Advantage: The state maintains a public database of IRO decisions for transparency and precedent research.
Consumer Support
Washington Office of the Insurance Commissioner:
- Phone: 1-800-562-6900 (Consumer Advocacy)
- Website: insurance.wa.gov
- Appeals guidance: How to Appeal a Health Insurance Denial
Cost Assistance Options
Manufacturer Support
Ultragenyx may offer patient assistance programs. Contact the manufacturer directly for current eligibility requirements and application processes.
Foundation Grants
Several rare disease foundations provide medication assistance for LC-FAOD patients. Research current programs through organizations focused on metabolic disorders.
Washington State Programs
Washington's Apple Health (Medicaid) may cover Dojolvi for eligible patients. The state also has various pharmaceutical assistance programs for qualifying individuals.
Quick Audit Checklist
Before submitting your Dojolvi prior authorization:
- ICD-10 code E71.318 documented
- Molecular genetic testing results included
- MCT oil discontinuation documented
- Metabolic specialist involvement confirmed
- Dosing calculated in mL based on DCI
- HCPCS J8499 with correct NDC
- All required forms completed
- Supporting clinical notes attached
- Submission method verified with Aetna
FAQ
How long does Aetna CVS Health prior authorization take for Dojolvi? Standard decisions typically take 30-45 days. Expedited reviews (for urgent medical situations) are completed within 72 hours.
What if Dojolvi is non-formulary on my Aetna plan? You can request a formulary exception by submitting clinical documentation showing medical necessity and failure of or contraindications to preferred alternatives.
Can I request an expedited appeal in Washington? Yes, if delay in treatment could seriously jeopardize your health. Both Aetna internal appeals and Washington external reviews offer expedited timelines.
Does step therapy apply to Dojolvi? Aetna may require documentation of prior MCT oil trials or dietary management attempts. Washington law provides step therapy protections when medically inappropriate.
What happens if my external review is denied? While IRO decisions are binding on insurers, you can file a complaint with the Washington Office of the Insurance Commissioner if you believe the process was flawed.
How much does Dojolvi cost without insurance? Cash prices typically range from $5,857-$6,365 per 500-mL bottle, making insurance coverage essential for most patients.
About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed prior authorization requests and appeal letters. Our platform analyzes denial reasons and crafts point-by-point rebuttals aligned with each payer's specific requirements, significantly improving approval rates for complex specialty medications like Dojolvi.
Sources & Further Reading
- FDA Dojolvi Label and Prescribing Information
- Aetna Specialty Drug Prior Authorization Form
- Washington State External Review Process
- Dojolvi Dosing Calculator
- Washington Office of the Insurance Commissioner Appeals Guide
This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.
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