Answer Box: Getting Dojolvi Covered by Blue Cross Blue Shield in Ohio

You can get Dojolvi (triheptanoin) covered by Blue Cross Blue Shield Ohio, but it requires molecular confirmation of LC-FAOD and specialist oversight. Start by gathering genetic test results proving your long-chain fatty acid oxidation disorder diagnosis, then have your metabolic specialist submit prior authorization with a detailed medical necessity letter. If denied, Ohio offers strong appeal rights including external review through independent medical experts. First step today: Call your Blue Cross Blue Shield member services at the number on your card to confirm your specific plan's formulary status and PA requirements.

Table of Contents

1. Coverage Requirements at a Glance
2. Step-by-Step: Fastest Path to Approval
3. Medical Necessity Letter Essentials
4. Common Denial Reasons & How to Fix Them
5. Ohio Appeals Process: Your Rights
6. Scripts for Success
7. Cost-Saving Programs
8. FAQ

Coverage Requirements at a Glance

Requirement	What Blue Cross Blue Shield Ohio Needs	Where to Get It
Molecular Diagnosis	Genetic testing showing CPT2, ACADVL, HADHA, or HADHB mutations	Ultragenyx sponsored testing program
Specialist Prescriber	Board-certified medical geneticist or metabolic specialist	Find providers at ACMG directory
No MCT Products	Discontinue all medium-chain triglyceride supplements	Document in medical records
Dosage Limits	≤35% of total daily caloric intake	Registered dietitian calculation
Initial Coverage	12 months maximum per authorization	Reauthorization required annually

Source: Anthem Blue Cross Blue Shield Ohio PA requirements

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis (Patient + Family)

Who does it: You and your medical team
What's needed: Molecular genetic testing results
Timeline: 10-21 days if using sponsored testing
Action: If you haven't had genetic testing, enroll in the Ultragenyx no-cost program (U.S. residents only)

2. Establish Specialist Care (Patient)

Who does it: You
What's needed: Appointment with metabolic specialist
Timeline: 2-8 weeks depending on availability
Action: Board-certified medical geneticists have the strongest credibility with insurers

3. Gather Treatment History (Clinic Staff)

Who does it: Your care team
What's needed: Documentation of failed dietary management, MCT intolerance
Timeline: 1-2 days to compile records
Action: Include nutritionist assessments, hospitalization records, symptom logs

4. Submit Prior Authorization (Specialist Office)

Who does it: Prescribing physician's office
What's needed: PA form, medical necessity letter, supporting documents
Timeline: Submit via Blue Cross Blue Shield provider portal
Action: Include genetic results, specialist credentials, treatment rationale

5. Follow Up Proactively (You + Clinic)

Who does it: Both patient and provider office
What's needed: Reference numbers, submission confirmations
Timeline: Blue Cross Blue Shield typically responds within 5-10 business days
Action: Call member services if no response after 10 days

Tip: Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting targeted rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements for specialty medications like Dojolvi.

Medical Necessity Letter Essentials

Your metabolic specialist's medical necessity letter should address these key points:

Patient-Specific Clinical Information:

• Confirmed LC-FAOD diagnosis with specific genetic mutations
• Clinical manifestations (rhabdomyolysis episodes, cardiac complications)
• Failed response to standard dietary management and MCT supplements
• Contraindications or intolerance to alternative therapies

Treatment Rationale:

• Dojolvi as the only FDA-approved therapy for LC-FAOD
• Expected clinical benefits (reduced hospitalizations, improved energy metabolism)
• Specific dosing plan not exceeding 35% of daily caloric intake
• Monitoring plan including labs and specialist visits

Supporting Evidence:

• Reference to FDA approval and labeling
• Peer-reviewed literature on triheptanoin efficacy
• Professional society guidelines supporting treatment

Common Denial Reasons & How to Fix Them

Denial Reason	Blue Cross Blue Shield's Concern	How to Overturn
"Lack of molecular confirmation"	No genetic proof of LC-FAOD	Submit complete genetic testing results showing pathogenic mutations
"Concurrent MCT use"	Patient still taking other MCT products	Document discontinuation of all MCT supplements in medical records
"Not prescribed by specialist"	Primary care physician submitted PA	Transfer prescription to board-certified metabolic specialist
"Exceeds quantity limits"	Dosing above 35% daily calories	Registered dietitian letter justifying specific caloric needs
"Alternative therapies available"	Standard dietary management not tried	Document failed trials of MCT oil, carnitine, dietary restrictions

Ohio Appeals Process: Your Rights

Ohio offers strong consumer protections for insurance appeals:

Internal Appeal (Required First Step)

• Timeline: Submit within 60 days of denial
• Process: Write to Blue Cross Blue Shield appeals department
• Response time: 30 days for standard, 72 hours for urgent
• What to include: Denial letter, new medical evidence, specialist letter

External Review (Independent Medical Experts)

• Timeline: Request within 180 days of final internal denial
• Process: Submit Ohio External Review Request Form
• Cost: Free to consumers
• Success rate: 36% of cases overturned in 2017 (over $1.17 million in benefits)
• Binding: Decision is final and enforceable

Note: Contact the Ohio Department of Insurance consumer hotline at 800-686-1526 for assistance with the appeals process.

From Our Advocates

"We've seen Dojolvi appeals succeed when families provide comprehensive genetic documentation and work with metabolic specialists who understand insurance language. One key factor: addressing every single denial reason point-by-point rather than submitting generic appeals. The peer-to-peer review is often the turning point—having your specialist speak directly with the plan's medical director can clarify complex metabolic concepts that may not translate well in written form."

Scripts for Success

Patient Script for Blue Cross Blue Shield Member Services

"Hi, I'm calling about prior authorization for Dojolvi, generic name triheptanoin, for my diagnosed long-chain fatty acid oxidation disorder. Can you please tell me:

• Is Dojolvi on my plan's formulary?
• What's the specific prior authorization form number?
• Do you have a specialty pharmacy requirement?
• What's the typical processing timeline? My member ID is [number]. Thank you."

Clinic Script for Peer-to-Peer Review Request

"I'm calling to schedule a peer-to-peer review for a Dojolvi prior authorization that was denied. The patient has genetically confirmed LC-FAOD, and I'm a board-certified medical geneticist. I have the molecular testing results and can explain why this is the only appropriate therapy. When is your medical director available for a 15-minute discussion? Reference number is [PA number]."

Cost-Saving Programs

Even with insurance coverage, Dojolvi can be expensive. These programs may help:

Ultragenyx Patient Assistance:

• Copay assistance for eligible commercial insurance patients
• Patient assistance program for uninsured/underinsured
• Contact: Dojolvi patient support

State and Federal Programs:

• Ohio Medicaid may cover Dojolvi with prior authorization
• Medicare Part D coverage varies by plan
• State pharmaceutical assistance programs (verify eligibility)

FAQ

How long does Blue Cross Blue Shield PA take in Ohio? Standard prior authorization decisions are typically made within 5-10 business days. Urgent requests (when delay could jeopardize health) must be decided within 72 hours.

What if Dojolvi is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and lack of appropriate alternatives. Include documentation of failed standard therapies and specialist support.

Can I request an expedited appeal if my PA is denied? Yes, if your physician certifies that a delay in treatment could seriously jeopardize your health. Expedited appeals in Ohio are resolved within 72 hours.

Does step therapy apply to Dojolvi? Blue Cross Blue Shield may require documentation that you've tried and failed standard LC-FAOD management (dietary therapy, MCT supplements, carnitine) before approving Dojolvi.

What happens if my external review is denied? While external review decisions are binding on insurers, you retain the right to seek other remedies, including legal action or filing complaints with state regulators.

How much will I pay out-of-pocket? With insurance approval, copays typically range from $50-$200 per month depending on your formulary tier. Without coverage, Dojolvi costs approximately $5,857-$6,365 per 500-mL bottle.

When to Get Help

Consider professional assistance if:

• Your initial PA is denied despite complete documentation
• You're facing tight appeal deadlines
• The peer-to-peer review didn't result in approval
• You need help navigating Ohio's external review process

Counterforce Health specializes in analyzing insurance denials and crafting evidence-backed appeals that address payers' specific concerns. Their platform helps identify denial patterns and creates targeted rebuttals aligned with each plan's policies.

Sources & Further Reading

• Anthem Blue Cross Blue Shield Ohio PA Requirements
• Ohio Department of Insurance External Review Process
• Dojolvi FDA Prescribing Information
• Ultragenyx LC-FAOD Genetic Testing Program
• Ohio Insurance Consumer Hotline: 800-686-1526

---

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by individual plan and change frequently. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult with your healthcare providers regarding treatment decisions. For personalized assistance with insurance appeals, contact qualified patient advocates or legal professionals.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.