By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (triheptanoin) Covered by Cigna in California: Complete PA Requirements and Appeals Guide

Quick Answer: Getting Dojolvi (triheptanoin) Covered by Cigna in California

Cigna requires prior authorization for Dojolvi (triheptanoin) with molecular confirmation of LC-FAOD diagnosis, specialist prescribing, and documented MCT oil discontinuation. Submit through Express Scripts/Accredo with genetic testing results, treatment history, and medical necessity letter. If denied, file internal appeal within 180 days, then request California DMHC Independent Medical Review (IMR) for external review. California's IMR success rate for specialty drugs is approximately 68%.

First step today: Have your metabolic specialist gather genetic test results, prior therapy documentation, and submit PA through CoverMyMeds or ExpressPAth.

Table of Contents

Cigna's Coverage Policy Overview

Cigna covers Dojolvi (triheptanoin) for long-chain fatty acid oxidation disorders (LC-FAOD) under their specialty pharmacy benefit, managed through Express Scripts and dispensed via Accredo specialty pharmacy. Coverage applies to all Cigna plan types in California—HMO, PPO, and EPO—but requires prior authorization regardless of plan structure.

Plan Types and Policy Application

  • HMO plans: Subject to network restrictions; specialist referrals may be required
  • PPO plans: More flexibility in provider choice but same PA requirements
  • Medicare Advantage: Additional Medicare guidelines may apply
  • Medicaid (Medi-Cal managed care): State Medicaid criteria overlay Cigna requirements
Note: California has two insurance regulators—DMHC for HMOs and most PPOs, and CDI for other policies. This affects your appeal rights.

Medical Necessity Requirements

Cigna's medical necessity criteria for Dojolvi center on molecular confirmation of LC-FAOD and specialist involvement. The drug must be prescribed for its FDA-approved indication: as a source of calories and fatty acids for patients with molecularly confirmed LC-FAOD.

Core Eligibility Criteria

  1. Molecular/genetic confirmation of LC-FAOD with laboratory documentation
  2. ICD-10 diagnosis codes E71.310–E71.318 (specific LC-FAOD subtypes)
  3. Prescribing by or consultation with a metabolic specialist or geneticist
  4. Patient age: FDA-approved for all ages (pediatric and adult)
  5. Exclusions: No pancreatic insufficiency; no concurrent pancreatic lipase inhibitor use

Specialist Requirements

Cigna typically requires prescribing by or consultation with:

  • Metabolic medicine specialist
  • Clinical geneticist
  • Pediatric metabolic specialist (for children)
  • Endocrinologist with metabolic expertise

The specialist must provide clinical rationale for why Dojolvi is medically necessary and document the patient's risk of metabolic decompensation without treatment.

Step Therapy and MCT Oil Requirements

Critical requirement: All medium-chain triglyceride (MCT) products must be discontinued before starting Dojolvi. This is both an FDA safety requirement and universal payer policy.

MCT Oil Step Therapy Documentation

Cigna requires evidence that the patient was:

  1. Symptomatic despite ≥90 days of MCT oil therapy (unless contraindicated)
  2. Unable to tolerate MCT oil due to adverse effects, or
  3. Had medical contraindication to MCT oil therapy

Transition Protocol

When switching from MCT oil to Dojolvi:

  • Start Dojolvi at the last tolerated daily MCT dosage (mL)
  • Divide into at least 4 doses per day
  • Titrate up by 5% of daily caloric intake every 2-3 days
  • Target maximum of 35% daily caloric intake as tolerated
Tip: Document the exact date MCT oil was discontinued and when Dojolvi was initiated—audits will check for overlap.

Required Documentation Checklist

For Initial Prior Authorization

  • Genetic testing report showing pathogenic variant for LC-FAOD
  • ICD-10 diagnosis code (E71.310–E71.318 range)
  • Medical necessity letter from prescribing specialist
  • Treatment history including:
    • Duration and response to MCT oil therapy
    • Adverse effects or contraindications to MCT
    • Date MCT oil was discontinued
    • Other dietary therapies attempted
  • Clinical rationale for Dojolvi necessity
  • Dosing plan with target caloric percentage
  • Exclusion of pancreatic insufficiency

Medical Necessity Letter Template Elements

Your specialist's letter should include:

  1. Patient's molecular LC-FAOD diagnosis with genetic confirmation
  2. Prior dietary therapies attempted and outcomes
  3. Clinical symptoms and metabolic decompensation risk
  4. Rationale for Dojolvi vs. continued dietary management
  5. Dosing plan and monitoring approach
  6. Specialist qualifications and experience with LC-FAOD

Express Scripts/Accredo Specialty Pharmacy Process

Dojolvi must be dispensed through Accredo specialty pharmacy for Cigna members. The medication cannot be filled at retail pharmacies.

Submission Process

  1. Prior authorization: Submit through CoverMyMeds or ExpressPAth portal
  2. Prescription routing: Send directly to Accredo (not retail pharmacy)
  3. Patient enrollment: Accredo will contact patient for intake and insurance verification
  4. Delivery: Shipped to patient's home with temperature-controlled packaging

Timelines

  • Standard PA decision: 72 hours
  • Urgent/expedited: 24 hours
  • Specialty pharmacy setup: 3-5 business days after approval
  • First shipment: 7-10 days from approval
Note: If Cigna doesn't respond within these timeframes, the request may be deemed approved in some jurisdictions.

Appeals Process: Internal and California IMR

If Cigna denies your Dojolvi prior authorization, California provides robust appeal rights through both internal processes and external review.

Internal Appeals with Cigna

  1. File within 180 days of denial notice
  2. Submit additional documentation addressing denial reasons
  3. Request peer-to-peer review with metabolic specialist
  4. Timeline: 30 days for standard, 72 hours for expedited
  5. Second-level internal appeal available if first level denied

California DMHC Independent Medical Review (IMR)

After exhausting Cigna's internal appeals, California residents can request external review:

Eligibility for IMR

  • Plan is DMHC-regulated (most HMOs and PPOs)
  • Denial based on "not medically necessary" or "experimental/investigational"
  • Internal appeal completed or 30 days elapsed

IMR Process

  1. File within 6 months of final internal denial
  2. No cost to patient for IMR
  3. Timeline: 30 days standard, 3-7 days expedited
  4. Success rate: Approximately 68% for specialty drugs
  5. Binding decision: Cigna must comply within 5 days if overturned

DMHC Contact Information

  • Help Center: (888) 466-2219
  • Online application: healthhelp.ca.gov
  • Languages: Available in multiple languages

Common Denial Reasons and Solutions

Denial Reason Solution
Missing molecular confirmation Submit genetic testing report with pathogenic variant
Insufficient MCT oil trial Provide documentation of ≥90 days MCT therapy or contraindication
Not prescribed by specialist Have metabolic specialist co-sign or provide consultation note
Concurrent MCT use Document MCT discontinuation date before Dojolvi start
Lack of medical necessity Submit detailed letter with clinical rationale and decompensation risk
Quantity limit exceeded Request exception with dosing justification based on caloric needs

Strengthening Your Appeal

  • Include peer-reviewed literature supporting Dojolvi for LC-FAOD
  • Reference FDA approval and prescribing information
  • Document hospitalizations or metabolic crises on current therapy
  • Provide specialist attestation of medical necessity
  • Include patient/family impact statement

Cost Considerations and Patient Support

Dojolvi's high cost—approximately $5,857–$6,365 per 500-mL bottle—makes coverage crucial for most families.

Financial Assistance Options

  • Ultragenyx patient support program: Copay assistance and free drug programs
  • Foundation grants: National Organization for Rare Disorders (NORD), others
  • State programs: California may have additional rare disease support
  • Cigna specialty copay programs: Check member benefits for specialty tier copays

Coverage Verification

Before starting therapy:

  1. Confirm Dojolvi is covered under specialty benefit
  2. Verify copay/coinsurance amount
  3. Check annual/lifetime maximums
  4. Understand prior authorization renewal requirements (typically annual)

California-Specific Rights and Resources

California provides exceptional consumer protections for insurance denials, particularly for rare disease treatments.

State Regulatory Resources

  • DMHC (for HMOs/most PPOs): (888) 466-2219
  • California Department of Insurance (for other plans): (800) 927-4357
  • Health Consumer Alliance: Consumer advocacy and appeal assistance
  • Legal aid organizations: Free help for complex appeals

California Advantages

  • No fee for Independent Medical Review
  • High success rates for specialty drug appeals
  • Strong step-therapy override protections
  • Expedited review available for urgent cases
  • Multiple language support for all processes
From our advocates: We've seen LC-FAOD families succeed with California IMR by providing comprehensive genetic documentation and specialist letters emphasizing metabolic decompensation risk. The key is thorough preparation—California's independent reviewers are typically well-versed in rare disease cases and respond favorably to strong clinical evidence.

When Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Dojolvi. Our platform analyzes denial letters, identifies the specific coverage gaps, and drafts point-by-point rebuttals aligned to Cigna's own policies. For LC-FAOD cases, we pull the right clinical evidence—FDA labeling, metabolic guidelines, and peer-reviewed studies—and weave them into appeals that meet California's procedural requirements while tracking deadlines and required documentation.

FAQ

How long does Cigna prior authorization take for Dojolvi in California? Standard decisions take 72 hours; urgent cases are decided within 24 hours. If Cigna doesn't respond within these timeframes, some jurisdictions deem the request approved.

What if Dojolvi is not on Cigna's formulary? Request a formulary exception through Express Scripts with clinical justification. If denied, appeal internally then file California DMHC IMR.

Can I get expedited appeals in California? Yes, both Cigna internal appeals and DMHC IMR offer expedited pathways for urgent medical situations—typically 72 hours for internal, 3-7 days for IMR.

Do step therapy requirements apply if I tried MCT oil outside California? Yes, prior therapy documentation from any state counts toward step therapy requirements, as long as you have medical records.

What happens if my metabolic specialist isn't in Cigna's network? For HMO plans, request a network exception. For PPO plans, you may see out-of-network specialists but with higher costs. The specialist can still provide consultation notes for in-network providers.

How often does Dojolvi prior authorization need renewal? Typically annually. Start the renewal process 30-60 days before expiration with updated clinical documentation showing continued benefit.

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 policy terms. Always consult your healthcare providers and insurance representatives for guidance specific to your situation. For assistance with California insurance complaints or appeals, contact the DMHC Help Center at (888) 466-2219 or visit healthhelp.ca.gov.

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