By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by Blue Cross Blue Shield in Washington: Forms, Appeals, and Provider Resources

Quick Start: Getting Dojolvi Covered by Blue Cross Blue Shield in Washington

Blue Cross Blue Shield plans in Washington (Premera Blue Cross, Regence BlueShield) require prior authorization for Dojolvi (triheptanoin) with molecular confirmation of long-chain fatty acid oxidation disorder (LC-FAOD). The fastest path: (1) Gather genetic test results confirming LC-FAOD diagnosis, (2) Submit prior authorization using your plan's pharmacy portal or fax form with clinical documentation, and (3) Enroll in UltraCare patient support program simultaneously. Most approvals come within 5 calendar days for standard requests, 48 hours for urgent cases.

Table of Contents

Verify Your Plan & Find Resources

Before starting your Dojolvi prior authorization, confirm which Blue Cross Blue Shield plan you have in Washington. The two main carriers have different processes:

Premera Blue Cross

  • Coverage area: Most of Washington state
  • Member services: 800-722-1471
  • Provider portal: premera.com/wa/provider
  • Pharmacy services: 888-261-1756

Regence BlueShield

  • Coverage area: Select Washington counties
  • Member services: 800-552-0733
  • Provider portal: regence.com
  • Precertification: 800-344-2227

Check your insurance card for the specific carrier name and member ID format to ensure you're using the correct resources.

Required Forms & Documentation

Both Premera and Regence require comprehensive documentation for Dojolvi approval. Here's what you need:

Coverage Criteria Checklist

  • ✅ Molecular confirmation: Genetic test results showing pathogenic mutations in LC-FAOD genes (ACADVL, CPT2, HADHA, HADHB, etc.)
  • ✅ Diagnosis documentation: Clinical notes confirming long-chain fatty acid oxidation disorder
  • ✅ Medication list: Proof that other medium-chain triglyceride (MCT) products have been discontinued
  • ✅ Prescriber information: Licensed physician details and DEA number

Premera Blue Cross Requirements

Premera's 2024 criteria specify that Dojolvi requires prior authorization with:

  • Molecularly confirmed LC-FAOD diagnosis
  • No concurrent MCT product use
  • Initial authorization granted for 12 months
  • Reauthorization requires documented clinical benefit

Submit using Premera's Pharmacy Prior Authorization Request form, available through their provider portal.

Regence BlueShield Requirements

Regence follows similar molecular confirmation requirements and processes requests through CoverMyMeds portal for registered providers.

Tip: Gather genetic testing reports before starting the PA process. These are the most critical documents for approval.

Submission Portals & Methods

Online Submission (Fastest)

Premera providers: Use the provider portal pharmacy section Regence providers: Register for CoverMyMeds integration

Fax Submission

  • Premera: Use fax number provided on current PA forms (verify on provider portal)
  • Regence: Submit to precertification fax line

Required Attachments

  1. Completed prior authorization form
  2. Genetic test results (molecular confirmation)
  3. Clinical notes documenting LC-FAOD diagnosis
  4. Current medication list
  5. Prescriber attestation of medical necessity

Processing times: 5 calendar days for standard requests, 48 hours for urgent cases requiring expedited review.

Specialty Pharmacy Enrollment

Dojolvi requires specialty pharmacy dispensing. Start this process simultaneously with prior authorization:

UltraCare Patient Services Enrollment

  1. Download the DOJOLVI Start Form from dojolvi.com/resources
  2. Complete patient, insurance, and prescriber sections
  3. Obtain patient/caregiver consent for benefit coordination
  4. Submit via fax to UltraCare at 415-723-7474 or call 888-756-8657

Required Information

  • Patient demographics and contact information
  • Insurance cards (front and back copies)
  • Prescriber information and signature
  • HIPAA authorization for UltraCare coordination

UltraCare will handle benefits investigation and coordinate with your Blue Cross Blue Shield plan's specialty pharmacy network.

Support Contacts

Member Services

  • Premera Blue Cross: 800-722-1471 (M-F, 8am-5pm)
  • Regence BlueShield: 800-552-0733

Provider Services

  • Premera pharmacy services: 888-261-1756
  • Regence precertification: 800-344-2227

Case Management

For complex cases requiring additional support:

  • Premera care management: 844-996-0329
  • Regence care management: 800-552-0733

UltraCare Patient Support

  • Phone: 888-756-8657
  • Fax: 415-723-7474
  • Provides benefits investigation, prior authorization support, and specialty pharmacy coordination

Appeals Process in Washington

If your initial prior authorization is denied, Washington provides strong consumer protections for appeals.

Internal Appeals (Required First Step)

  1. File within: 180 days of denial notice
  2. Submit to: Your Blue Cross Blue Shield plan's appeals department
  3. Include: Original denial letter, additional clinical evidence, prescriber letter of medical necessity

External Review (Independent Review Organization)

After exhausting internal appeals, Washington residents can request external review:

  1. Contact: Washington Office of the Insurance Commissioner at 800-562-6900
  2. Timeline: Request within 180 days of final internal denial
  3. Process: Independent medical experts review your case
  4. Decision: Binding on the insurance company if overturned

Template for External Review Request:

Date: [Current Date]

To: [Blue Cross Blue Shield Plan Name]
Cc: Washington State Office of the Insurance Commissioner

Subject: Request for External Independent Review – Denial of Dojolvi (triheptanoin)

Enrollee Name: [Your Name]
Policy Number: [Policy Number]
Claim Number: [If applicable]

I am requesting an external independent review of my health plan's final adverse benefit determination dated [date], which denied coverage for Dojolvi (triheptanoin) prescribed to treat my molecularly confirmed long-chain fatty acid oxidation disorder.

Given the specialized nature of LC-FAOD, I request that the assigned IRO include reviewers with expertise in rare metabolic disorders. Please confirm receipt and provide IRO contact information.

Attachments:
- Denial and appeal letters
- Genetic test results confirming LC-FAOD
- Clinical documentation
- Published treatment guidelines

Sincerely,
[Your signature and contact information]

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing molecular confirmation Submit genetic test results Pathogenic mutation report from certified lab
Concurrent MCT use Discontinue other MCT products Updated medication list showing discontinuation
Insufficient clinical documentation Provide comprehensive medical records Specialist notes, metabolic workup, treatment history
Not medically necessary Submit medical necessity letter Prescriber attestation with clinical rationale

Medical Necessity Letter Template

Your prescriber should include:

  • Patient's specific LC-FAOD genetic mutation
  • Clinical presentation and metabolic decompensation history
  • Previous dietary management attempts
  • Expected clinical benefits of Dojolvi therapy
  • Monitoring plan and treatment goals

Patient Assistance Programs

Manufacturer Support

UltraCare Patient Services provides:

  • Insurance navigation and prior authorization support
  • Copay assistance for eligible patients
  • Specialty pharmacy coordination
  • Ongoing therapy support

Contact: 888-756-8657

Foundation Assistance

For patients facing financial hardship, research patient assistance foundations that support rare disease medications. UltraCare can provide current foundation listings and application assistance.

Clinician Corner: Optimizing Your Prior Authorization

Medical Necessity Documentation Checklist

Include these elements in your prior authorization submission:Specific genetic mutation(s) identified in LC-FAOD testingClinical history of metabolic decompensation episodesCurrent dietary management plan and limitationsExpected clinical outcomes with Dojolvi therapyMonitoring parameters and follow-up scheduleReferences to FDA labeling and clinical guidelines

Counterforce Health helps clinicians and patients navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-based appeals tailored to specific payer policies.

FAQ

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard requests are processed within 5 calendar days. Urgent requests requiring expedited review are completed within 48 hours.

What if Dojolvi is not on my plan's formulary? You can request a formulary exception by demonstrating medical necessity and providing documentation that standard alternatives are inappropriate for LC-FAOD treatment.

Can I request an expedited appeal? Yes, if your health could be seriously jeopardized by delays. Contact your plan's urgent review line and provide clinical documentation supporting the urgency.

Does step therapy apply to Dojolvi? Generally no, since Dojolvi is the only FDA-approved therapy specifically for LC-FAOD. However, plans may require documentation of previous dietary management attempts.

What if my employer plan is self-funded? Self-funded plans may not be subject to Washington state appeal rights. Contact the U.S. Department of Labor for ERISA plan appeals, or check if your employer voluntarily provides external review options.

How much does Dojolvi cost without insurance? Cash prices typically range from $5,857-$6,365 per 500-mL bottle. UltraCare patient services can provide current pricing and assistance options.

When Coverage Gets Complex

For challenging cases involving multiple denials or complex clinical situations, Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting targeted, evidence-based rebuttals that align with plan-specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Insurance policies and requirements may change; verify current information with official sources before submitting requests.

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