By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (triheptanoin) Covered by Humana in New York: Complete Prior Authorization Guide with Appeals Process

Answer Box: Getting Dojolvi Covered by Humana in New York

Humana requires prior authorization for Dojolvi (triheptanoin) with molecular confirmation of LC-FAOD diagnosis, specialist prescription, and discontinuation of other MCT products. For New York Medicare Advantage patients, use Medicare's appeal process (not state external appeals). First step today: Call member services to verify your plan type and formulary status, then gather genetic test results and specialist documentation.

Quick 3-step path:

  1. Verify coverage via Humana member portal or call the number on your ID card
  2. Submit PA with molecular LC-FAOD confirmation and specialist prescription
  3. If denied, file Medicare appeal within 65 days (standard) or request expedited review

Table of Contents

Who Should Use This Guide

This guide helps New York patients with confirmed long-chain fatty acid oxidation disorders (LC-FAOD) get Dojolvi (triheptanoin) covered by Humana. You'll need this if you have:

  • Humana Medicare Advantage with Part D coverage
  • Molecular confirmation of LC-FAOD (genetic testing results)
  • A prescription from a metabolic specialist
  • Prior therapy failures or intolerance to MCT oils

Expected outcome: With complete documentation, approval rates are high for confirmed LC-FAOD cases meeting Humana's criteria.

Member & Plan Basics

Verify Your Coverage First

Check This How to Verify Why It Matters
Plan Type Call member services on your ID card Medicare Advantage follows federal appeal rules, not NY state
Formulary Status Humana Drug List Search Non-formulary requires separate exception request
Deductible Member portal or phone High-cost specialty drug may require meeting annual deductible
PA Required Check with member services Confirms prior authorization needed
Tip: Humana's specific policy for Dojolvi (triheptanoin) Oral Liquid is active with review date 1/21/2026, confirming utilization management requirements.

Clinical Criteria for Approval

Humana requires these clinical elements for Dojolvi approval:

Primary Requirements

  • Molecular confirmation via genetic testing results showing LC-FAOD mutations (ACADVL, CPT1A, CPT2, HADHA/HADHB, or related genes)
  • Biochemical evidence including elevated long-chain acylcarnitines (C14-C18) via tandem mass spectrometry
  • Specialist prescription from board-certified medical geneticist or metabolic specialist
  • MCT discontinuation - all other medium-chain triglyceride products must be stopped

Clinical Documentation

  • ICD-10 codes: E71.310 (Long chain/very long chain acyl CoA dehydrogenase deficiency) or E71.318 (Other specified disorders of fatty-acid oxidation)
  • Prior therapy records: Documentation of inadequate response or intolerance to MCT oils, dietary therapies, hospitalizations, or complications
  • Dosing requirements: Up to 35% of daily caloric intake in ≥4 divided doses
  • Disease-specific diet plan coordinated with metabolic specialist

Documentation Requirements

Essential Documents Checklist

  • Genetic test results confirming LC-FAOD diagnosis
  • Acylcarnitine profile showing elevated long-chain species
  • Specialist prescription with credentials verification
  • Prior therapy failure documentation
  • Medical necessity letter from prescribing physician
  • Current insurance card and member ID

Medical Necessity Letter Components

Your specialist should include:

  • Problem statement: LC-FAOD diagnosis with molecular confirmation
  • Prior treatments: MCT oils tried, outcomes, reasons for discontinuation
  • Clinical rationale: Why Dojolvi is medically necessary for this specific patient
  • Dosing plan: Target percentage of daily calories, divided doses
  • Monitoring plan: Follow-up schedule and safety assessments

Submission Process

Step-by-Step Submission

  1. Verify network provider - Ensure prescribing specialist is in Humana's network
  2. Complete PA form - Use Humana Prior Authorization Search Tool to find current form
  3. Submit documentation - Via provider portal, fax, or mail as specified on form
  4. Request expedited if urgent - Include physician certification if delay risks health

Timeline Expectations

  • Standard decision: 7 days for Medicare Part D
  • Expedited decision: 24-72 hours with physician certification
  • Status checks: Track via provider portal or member services

Specialty Pharmacy Network

Humana requires use of designated specialty pharmacy for Dojolvi:

Preferred Network

  • CenterWell Specialty Pharmacy - Humana's preferred vendor for specialty medications
  • Services included: Patient enrollment, insurance verification, clinical support, refrigerated shipping if needed
  • Contact: Available through Humana provider portal after PA approval

Post-Approval Steps

  1. Transfer prescription to network specialty pharmacy
  2. Complete patient enrollment and benefits verification
  3. Coordinate delivery and dosing instructions
  4. Set up refill schedule and monitoring

After Submission: What to Expect

Track Your Request

  • Confirmation number: Record from submission
  • Status checks: Weekly via member portal or phone
  • Communication: Monitor for requests for additional information

Approval Process

Once approved, expect:

  • Coverage determination letter
  • Specialty pharmacy contact information
  • Instructions for first fill and ongoing refills

Appeals Process in New York

Important: New York Medicare Advantage patients must use Medicare appeals, not state external appeals.

Medicare Appeal Levels

Level Timeline Process Contact
Level 1 (Redetermination) 65 days from denial Submit Humana Request for Redetermination form Member services on ID card
Level 2 (IRE Review) 60 days from Level 1 decision Independent review by Medicare contractor 1-800-MEDICARE
Expedited Appeals Any level 72 hours if delay harms health Physician certification required

Required for Appeals

  • Original denial letter
  • Medical records supporting necessity
  • Physician letter addressing denial reasons
  • Any new clinical information

For urgent cases where Counterforce Health helps patients turn insurance denials into targeted, evidence-backed appeals, the platform can identify denial basis and draft point-by-point rebuttals aligned to Humana's specific policy requirements.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Insufficient molecular proof Submit complete genetic testing results Lab report showing specific gene mutations
MCT products not discontinued Provide discontinuation records Physician note confirming MCT cessation
Non-formulary status Request formulary exception Medical necessity letter with alternatives tried
Quantity limits exceeded Justify dosing requirements Weight-based calculations and specialist rationale
Lack of specialist prescription Verify prescriber credentials Board certification documentation

Peer-to-Peer Review Script

"I'm requesting a peer-to-peer review for [patient name] regarding Dojolvi (triheptanoin) for confirmed LC-FAOD. We have molecular confirmation via genetic testing and documented MCT therapy failures. The patient has had [specific clinical events] and requires this FDA-approved therapy. When can we schedule the review with your medical director?"

Costs & Financial Assistance

Expected Costs

  • Cash price: $5,857–$6,365 per 500-mL bottle
  • Insurance coverage: Varies by deductible and copay structure
  • Specialty tier: Typically highest formulary tier

Assistance Programs

  • Ultragenyx UltraCare Program: Patient support services at 844-887-4337
  • NORD (National Organization for Rare Disorders): Patient assistance programs
  • Medicare Extra Help: Low-income prescription drug coverage

When navigating complex coverage requirements, Counterforce Health specializes in helping patients and clinicians get prescription drugs approved by turning insurance denials into evidence-backed appeals with the right citations and clinical facts.

FAQ

How long does Humana prior authorization take for Dojolvi in New York? Standard decisions take 7 days for Medicare Part D. Expedited reviews with physician certification take 24-72 hours.

What if Dojolvi is non-formulary on my Humana plan? Submit a formulary exception request with medical necessity documentation showing why covered alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if your physician certifies that delay would seriously jeopardize your health. Expedited Medicare appeals are decided within 72 hours.

Does step therapy apply to Dojolvi for LC-FAOD? Humana requires documentation of prior MCT therapy trials and failures, but this differs from traditional step therapy protocols.

What happens if I move to New York from another state? New Medicare Advantage members have 90 days of continued coverage for existing specialty medications while transitioning to new plan requirements.

Can I appeal to New York State if Humana denies coverage? No, Medicare Advantage patients must use federal Medicare appeals, not New York's state external appeal process through DFS.

From our advocates: "We've seen successful Dojolvi appeals when families include detailed genetic testing results and document specific clinical events like rhabdomyolysis episodes. The key is showing clear molecular confirmation and why standard MCT therapy failed for this particular patient's LC-FAOD variant."

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual circumstances and plan specifics. Consult your healthcare provider and insurance plan for personalized guidance. For additional help with insurance appeals in New York, contact Community Health Advocates at 888-614-5400.

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