By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by Humana in Illinois: Complete Prior Authorization Guide

Answer Box: To get Dojolvi (triheptanoin) covered by Humana in Illinois, you need prior authorization with molecular confirmation of LC-FAOD, discontinuation of other MCT products, and specialist prescribing. Submit through Humana's Prior Authorization Search Tool, expect 7-30 day decisions, and use Illinois' 65-day Medicare appeal window if denied. Start by gathering genetic test results and having your metabolic specialist complete Humana's drug-specific PA form.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding and Billing Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Common Denial Reasons & Solutions
  10. Appeals Process in Illinois
  11. Cost and Support Resources
  12. Frequently Asked Questions

Who Should Use This Guide

This comprehensive checklist is designed for Illinois residents with Humana coverage who need Dojolvi (triheptanoin) for long-chain fatty acid oxidation disorders (LC-FAOD). Whether you're a patient, caregiver, or healthcare provider, this guide provides the exact steps to navigate Humana's prior authorization process successfully.

Expected outcome: With proper documentation and molecular confirmation, most LC-FAOD patients meet Humana's medical necessity criteria. The key is submitting complete documentation upfront to avoid delays.

Member & Plan Basics

Coverage Verification

Before starting the PA process, confirm these basics:

  • Active Humana coverage with prescription drug benefits
  • Plan type: Medicare Advantage with Part D, stand-alone Part D, or commercial plan
  • Deductible status: High-cost specialty drugs may require meeting your annual deductible first
  • Specialty pharmacy requirement: Dojolvi typically requires use of Humana's designated specialty pharmacy network
Tip: Call the member services number on your ID card to verify your exact plan type and pharmacy benefits. This determines which appeal process applies if you're denied.

Humana's Dojolvi Policy

Humana maintains a specific Medical & Pharmacy Coverage Policy for Dojolvi (triheptanoin) with a policy date of February 19, 2025. This confirms Humana has established utilization management criteria for this orphan drug.

Clinical Criteria for Approval

Primary Requirements

Based on standard payer criteria for Dojolvi, Humana typically requires:

Requirement Documentation Needed Source
Molecular LC-FAOD confirmation ≥2 of: disease-specific acylcarnitine elevation, low enzyme activity, or genetic mutations UnitedHealthcare PA Policy
Specialist prescribing Board-certified medical geneticist or metabolic specialist Standard across payers
MCT discontinuation Attestation that other MCT products are discontinued FDA Label
Appropriate dosing ≤35% of total daily caloric intake, ≥4 divided doses Dojolvi prescribing information
Disease-specific diet plan Documentation of ongoing dietary management Clinical standard

Eligible Diagnoses

Submit with these ICD-10 codes:

  • E71.31 - Disorders of fatty-acid oxidation
  • E71.310 - Long chain/very long chain acyl-CoA dehydrogenase deficiency
  • E71.318 - Other disorders of fatty-acid oxidation

Step Therapy Considerations

Unlike many specialty drugs, Dojolvi is often approved without step therapy since it's the only FDA-approved therapy specifically for LC-FAOD. However, some plans may require documentation of:

  • Previous dietary management attempts
  • Prior use or contraindication to MCT oil products
  • Clinical manifestations despite optimal dietary therapy

Coding and Billing Requirements

HCPCS and NDC Information

  • HCPCS Code: J8499 (Prescription drug, oral, non-chemotherapeutic, NOS) when required for medical billing
  • NDC: Submit 11-digit NDC from actual dispensed product
  • Units: Typically billed in milliliters (mL)
  • Billing type: Usually processed under pharmacy benefit (Part D) rather than medical benefit
Note: Dojolvi is an oral liquid dosed as percentage of daily caloric intake. The exact mL amount varies by patient weight and caloric needs.

Documentation Packet Checklist

Required Clinical Documentation

Genetic/Molecular Confirmation:

  • Genetic testing results showing pathogenic variants in LC-FAOD genes (CPT2, ACADVL, HADHA, HADHB)
  • Acylcarnitine profile results (newborn screening or plasma)
  • Enzyme activity testing (if available)

Clinical History:

  • Documentation of LC-FAOD manifestations (rhabdomyolysis episodes, cardiomyopathy, hypoglycemia)
  • Prior hospitalizations or ER visits related to LC-FAOD
  • Current symptoms and functional limitations

Treatment History:

  • Previous dietary management attempts
  • MCT oil trials and outcomes (if applicable)
  • List of discontinued MCT products with dates

Prescriber Qualifications:

  • Board certification in medical genetics, metabolism, or related specialty
  • Clinical experience with LC-FAOD management

Medical Necessity Letter Components

Your specialist should include:

  1. Patient identification and confirmed LC-FAOD diagnosis with subtype
  2. Molecular confirmation method and results
  3. Clinical manifestations and impact on daily functioning
  4. Prior treatment attempts and limitations of dietary management alone
  5. Rationale for Dojolvi as FDA-approved therapy for LC-FAOD
  6. Proposed dosing plan with caloric intake calculations
  7. Monitoring plan and expected clinical outcomes

Submission Process

Step-by-Step Submission

  1. Access Humana's PA tools via the Provider Portal
  2. Search for Dojolvi in the Prior Authorization Search Tool
  3. Download the correct PA form (plan-specific)
  4. Complete all required fields - incomplete forms are commonly rejected
  5. Attach supporting documentation per checklist above
  6. Submit electronically through portal or via fax (confirm current fax number)
  7. Record confirmation number and submission date
Important: Humana's PA requirements are plan-specific. Always verify the exact form and criteria for your member's specific plan.

Expected Timelines

  • Standard PA decision: 7-30 days depending on plan type
  • Expedited PA: 24-72 hours for urgent medical situations
  • Medicare Part D appeals: 7 days standard, 72 hours expedited

Specialty Pharmacy Routing

Humana's Specialty Pharmacy Network

Dojolvi requires specialty pharmacy dispensing. After PA approval:

  1. Identify designated pharmacy through Humana member portal or pharmacy helpline
  2. Transfer prescription to approved specialty pharmacy
  3. Complete patient enrollment and insurance verification
  4. Coordinate shipment and storage requirements (refrigeration may be needed)
  5. Verify receipt and proper dosing instructions

Common Humana specialty pharmacy partners include CenterWell Specialty and other contracted vendors.

After Submission: What to Expect

Tracking Your Request

  • Confirmation number: Save from initial submission
  • Status checks: Monitor through provider portal or member services
  • Additional information requests: Respond promptly to avoid delays
  • Decision notification: Comes via portal, mail, or fax

Recording Important Information

Keep detailed records of:

  • Submission dates and confirmation numbers
  • All correspondence with Humana
  • Any additional documentation requests
  • Decision letters and appeal deadlines

Common Denial Reasons & Solutions

Denial Reason How to Fix Required Documentation
Insufficient molecular confirmation Submit complete genetic testing or enzyme studies Lab reports showing pathogenic variants or enzyme deficiency
Concurrent MCT use not addressed Provide attestation of MCT discontinuation Letter confirming other MCT products stopped
Lack of specialist involvement Ensure prescriber meets specialty requirements CV or board certification documentation
Dosing exceeds limits Recalculate dose ≤35% of daily calories Revised dosing calculation with caloric intake
Missing dietary management plan Document comprehensive LC-FAOD diet plan Dietitian notes and current dietary regimen

Appeals Process in Illinois

Medicare Part D Appeals (Most Common)

If you have Humana Medicare Part D coverage:

  1. Level 1 - Redetermination: File with Humana within 65 days using their Request for Redetermination form
  2. Level 2 - IRE Review: Independent review entity within 60 days of Level 1 decision
  3. Level 3-5: OMHA, Medicare Appeals Council, Federal Court

Illinois-Specific Resources

  • Illinois Department of Insurance: (877) 527-9431 for consumer assistance
  • Illinois Attorney General Health Care Helpline: (877) 305-5145
  • Illinois SHIP Program: Medicare counseling through Department on Aging
Critical Deadline: Illinois external review must be requested within 30 days for non-Medicare plans, but Medicare Part D follows federal timelines (65 days for initial appeal).

Counterforce Health helps patients navigate complex prior authorization and appeal processes by analyzing denial letters and crafting evidence-backed appeals that align with each payer's specific requirements. Their platform can identify the exact denial basis and draft targeted rebuttals using the right clinical evidence and policy citations.

Expedited Appeals

Request expedited review if:

  • Delay could seriously jeopardize your health
  • You're experiencing acute LC-FAOD symptoms
  • Current therapy is failing and you need immediate access

Cost and Support Resources

Financial Assistance Options

  • UltraCare Program: Manufacturer support for eligible patients
  • Dojolvi Start Form: Coverage assistance and PA support
  • Patient assistance foundations: Check eligibility for rare disease grants

Cash Pricing

If insurance fails, Dojolvi typically costs $5,857-$6,365 per 500-mL bottle, making manufacturer support programs crucial for access.

Frequently Asked Questions

Q: How long does Humana prior authorization take for Dojolvi? A: Standard PA decisions typically take 7-30 days depending on your plan type. Medicare Part D has specific 7-day timelines, while commercial plans may take longer.

Q: What if Dojolvi is non-formulary on my Humana plan? A: You can request a formulary exception with medical necessity documentation. The appeals process is the same as a PA denial.

Q: Can I get an expedited approval if I'm having LC-FAOD symptoms? A: Yes, if your prescriber documents that a delay could jeopardize your health, you can request expedited review (24-72 hours).

Q: Do I need to try other treatments first? A: Step therapy requirements vary by plan, but many approve Dojolvi without requiring other MCT oil trials since it's the only FDA-approved LC-FAOD therapy.

Q: What happens if I move to Illinois with existing Dojolvi coverage? A: Humana Medicare plans typically provide 90-day continuity of care for new members to avoid therapy interruption while PA is processed.

Q: Can I appeal to Illinois state regulators for Medicare Part D denials? A: No, Medicare Part D appeals follow federal processes through Independent Review Entities, not state insurance departments.

From our advocates: We've seen LC-FAOD families succeed by ensuring their metabolic specialist clearly documents the molecular confirmation and explains why dietary management alone is insufficient. The key is often in the details—showing specific acylcarnitine elevations and connecting them to clinical symptoms like exercise intolerance or cardiac issues.

Sources & Further Reading

If you're struggling with a Dojolvi denial or need help crafting a stronger appeal, Counterforce Health specializes in turning insurance denials into successful approvals by analyzing your specific situation and building evidence-backed appeals that speak directly to your payer's requirements.

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current policy requirements with your specific Humana plan. Coverage criteria and processes may change.

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