By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by Cigna in New Jersey: Complete PA Guide with Appeals Timeline

Answer Box: Getting Dojolvi Approved by Cigna in New Jersey

Cigna requires prior authorization for Dojolvi (triheptanoin) with strict criteria: molecular confirmation of LC-FAOD, specialist prescribing, documented MCT oil failure, and comprehensive clinical documentation. Fastest path: Submit complete PA with genetic testing, specialist letter, and MCT trial documentation via Express Scripts portal. Start today: Contact your metabolic specialist to gather required documentation and coordinate submission. If denied, New Jersey offers robust external review through IHCAP with high overturn rates.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. When Alternatives Make Sense
  4. Typical Formulary Alternatives
  5. Exception Strategy for Dojolvi
  6. Appeals Process in New Jersey
  7. Common Denial Reasons & Solutions
  8. Costs & Patient Support
  9. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Dojolvi prescriptions Express Scripts provider portal Cigna PA Forms
Molecular Confirmation Genetic testing confirming LC-FAOD Lab results with pathogenic mutations Cigna Policy CNF-463
Specialist Prescribing Metabolic specialist required Provider credentials documentation Cigna Policy CNF-463
MCT Oil Trial Must document failure/intolerance Clinical notes showing 90+ day trial Prime Therapeutics Criteria
Appeals Deadline 180 days for internal appeals Denial letter date Express Scripts FAQ
External Review IHCAP after internal appeals 4 months from final denial NJ DOBI IHCAP

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Patient and clinic staff
Timeline: 1-2 weeks
Documents needed:

  • Genetic testing results confirming LC-FAOD
  • Metabolic specialist consultation notes
  • MCT oil trial documentation (≥90 days)
  • Current clinical status and treatment history

2. Complete Cigna Prior Authorization Form

Who: Prescribing physician
Timeline: 2-3 business days
Submit via: Express Scripts provider portal or CoverMyMeds
Include: ICD-10 codes (E71.310-E71.318), specialist letter of medical necessity

3. Submit Comprehensive Clinical Package

Who: Clinic staff
Timeline: Same day as PA submission
Required attachments:

  • Letter of medical necessity addressing all denial criteria
  • Genetic test results
  • Specialist consultation notes
  • MCT oil failure documentation
  • Treatment history and clinical response data

4. Follow Up Within 5 Business Days

Who: Patient or clinic
Contact: Cigna member services at 1-800-882-4462
Verify: PA submission received and processing timeline

5. Prepare for Potential Peer-to-Peer Review

Who: Prescribing specialist
Timeline: Within 72 hours of request
Purpose: Direct discussion with Cigna medical director about clinical necessity

When Alternatives Make Sense

Before pursuing Dojolvi coverage, consider whether formulary alternatives might be appropriate for your specific clinical situation. Dojolvi is the only FDA-approved therapy for LC-FAOD, but Cigna requires documented failure of conventional therapies first.

Alternatives may be considered when:

  • Initial LC-FAOD diagnosis with mild symptoms
  • Patient hasn't tried MCT oil supplementation
  • Cost considerations are primary concern
  • Transitioning between therapies during coverage gaps

Dojolvi remains necessary when:

  • MCT oil has failed or caused intolerance
  • Severe LC-FAOD with recurrent metabolic crises
  • Specialist recommends based on clinical severity
  • Patient requires the unique anaplerotic mechanism

Typical Formulary Alternatives

Medium Chain Triglyceride (MCT) Oil

Coverage: Typically covered as medical food or supplement
Mechanism: Bypasses long-chain fatty acid oxidation pathway
Pros: Lower cost, readily available, established safety profile
Cons: May not provide adequate metabolic support for severe cases
Monitoring: Regular metabolic panels, growth parameters

Standard Dietary Management

Coverage: Nutritionist consultations often covered
Components: Low-fat diet, frequent feeding, fasting avoidance
Pros: Foundational therapy, covered by most plans
Cons: May be insufficient as monotherapy for moderate-severe LC-FAOD
Requirements: Metabolic dietitian involvement

Emergency Protocols

Coverage: Hospital/urgent care visits covered
Purpose: Acute management during metabolic crises
Components: IV glucose, carnitine supplementation
Integration: Works alongside any primary therapy

From Our Advocates: "We've seen patients successfully transition from MCT oil to Dojolvi after documenting clear treatment failure with detailed metabolic monitoring data. The key is working closely with your metabolic specialist to create a comprehensive record that demonstrates medical necessity—this approach has helped overcome initial denials in similar cases."

Exception Strategy for Dojolvi

Building Your Medical Necessity Case

Core arguments that strengthen approval:

  • Orphan drug status: Dojolvi has FDA orphan designation for rare LC-FAOD
  • Unique mechanism: Only therapy providing anaplerotic substrates
  • Clinical severity: Document metabolic crises, hospitalizations
  • Treatment failure: Comprehensive MCT oil trial documentation

Evidence to include:

  • Peer-reviewed literature on triheptanoin efficacy
  • FDA prescribing information and clinical trial data
  • Specialist society guidelines supporting use
  • Patient-specific clinical response data

Timing Your Request

Best timing for approval:

  • After documented 90+ day MCT oil trial
  • During metabolic specialist consultation
  • With complete genetic confirmation
  • Before current therapy gaps occur

Counterforce Health specializes in helping patients navigate complex prior authorization requirements for specialty medications like Dojolvi. Their platform analyzes denial patterns and creates targeted appeals based on payer-specific criteria, significantly improving approval rates for rare disease therapies.

Appeals Process in New Jersey

Internal Appeals with Cigna

First Level Internal Appeal

  • Deadline: 180 days from denial date
  • Submit to: Cigna appeals department via member portal
  • Include: Additional clinical evidence, specialist peer-to-peer request
  • Timeline: 30 days for standard, 72 hours for urgent

Second Level Internal Appeal

  • Automatic: If first level denied
  • Timeline: Additional 30 days
  • Review: Different medical director than first level

New Jersey External Review (IHCAP)

Eligibility: After completing Cigna's internal appeals
Deadline: 4 months (180 days) from final internal denial
Submit to: Maximus Federal Services (NJ's contracted IURO)
Cost: Free to patients (insurers pay all fees)
Timeline: 45 days for standard review, expedited available for urgent cases

IHCAP Process:

  1. Preliminary review within 5 business days
  2. Request additional information if needed (5 days to respond)
  3. Physician panel review with appropriate specialty expertise
  4. Binding decision on insurer (must comply within statutory timeframe)

Success rates: External reviews nationwide favor consumers in approximately 50% of cases, with higher rates for well-documented rare disease cases.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genetic confirmation Submit molecular testing results Lab report with pathogenic mutations
Insufficient MCT trial Document 90+ day trial with outcomes Clinical notes, metabolic panels, response data
Non-specialist prescriber Transfer care or obtain consultation Metabolic specialist involvement letter
Concurrent MCT use Discontinue and document cessation Medication reconciliation, specialist attestation
Quantity/dosing issues Justify based on weight/caloric needs Detailed dosing calculations, FDA labeling
Medical necessity unclear Strengthen clinical rationale Comprehensive letter addressing all criteria

Costs & Patient Support

Manufacturer Support Programs

  • Ultragenyx Connect: Patient assistance and copay support
  • Eligibility: Income-based assistance available
  • Contact: Dojolvi patient resources

New Jersey State Resources

  • NJ FamilyCare: Medicaid expansion coverage
  • CHIP: Children's coverage programs
  • Consumer assistance: NJ DOBI Consumer Hotline at 1-800-446-7467

Foundation Support

  • National Organization for Rare Disorders (NORD): Patient assistance programs
  • HealthWell Foundation: Copay assistance for eligible conditions
  • Patient Advocate Foundation: Case management and financial assistance

FAQ

How long does Cigna prior authorization take in New Jersey? Standard PA decisions are made within 10-15 business days. Urgent requests receive decisions within 72 hours. Express Scripts processes most PAs electronically for faster turnaround.

What if Dojolvi is non-formulary on my Cigna plan? You can request a formulary exception with medical necessity documentation. Include specialist letter, genetic confirmation, and evidence of MCT oil failure to support the exception request.

Can I request an expedited appeal in New Jersey? Yes, both Cigna internal appeals and NJ IHCAP external reviews offer expedited pathways when delays would cause serious harm to health. Document urgency with specialist support.

Does step therapy apply if I failed MCT oil outside New Jersey? Yes, documented MCT oil failure from any provider is acceptable. Ensure clinical notes clearly document the trial duration, dosing, and reasons for discontinuation or failure.

How do I know if my appeal was successful? Cigna must provide written notification of all PA and appeal decisions. For IHCAP external reviews, Maximus provides written decisions to both patient and insurer, with binding compliance requirements.

What happens if Cigna doesn't comply with an IHCAP decision? New Jersey law requires insurers to comply with IHCAP decisions. Non-compliance can be reported to NJ DOBI for regulatory action.

Sources & Further Reading

This guide is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. For specific questions about your coverage, contact Cigna member services directly. For assistance with New Jersey insurance appeals, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes by analyzing denial patterns and creating evidence-backed appeals tailored to specific payer requirements. Their platform has helped improve approval rates for specialty medications by providing targeted documentation and strategic appeal guidance.

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