By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by UnitedHealthcare in Florida: Complete Appeal Guide with Forms and Timelines

Answer Box: Getting Dojolvi Covered by UnitedHealthcare in Florida

Fast track to approval: Submit prior authorization with molecular/genetic confirmation of LC-FAOD from a board-certified medical geneticist, discontinue all MCT products, and include a detailed dietary management plan. If denied, file an internal appeal within 180 days citing Florida's step therapy exception laws (Florida Statute 627.42393). For urgent cases, request expedited review within 72 hours.

First step today: Contact your prescribing physician to gather genetic testing results and ensure they're board-certified in medical genetics or have metabolic specialist consultation documented.

Table of Contents

  1. Why Florida Insurance Laws Matter for Dojolvi Coverage
  2. UnitedHealthcare Prior Authorization Requirements
  3. Florida Step Therapy Protections and Medical Exceptions
  4. Continuity of Care During Plan Transitions
  5. Appeals Process: Internal and External Review
  6. Practical Scripts for Calls and Appeals
  7. When to File a State Complaint
  8. Cost Assistance and Patient Support
  9. Frequently Asked Questions
  10. Sources and Further Reading

Why Florida Insurance Laws Matter for Dojolvi Coverage

Florida's insurance regulations create specific protections that can help you get Dojolvi (triheptanoin) covered, even when UnitedHealthcare initially denies your request. The state's Patient Timely Access to Healthcare Act (PTAHA), effective October 2024, requires insurers to resolve standard appeals within 30 days maximum—cutting previous timelines in half.

More importantly, Florida Statute 627.42393 establishes formal procedures for step therapy exceptions. This matters because UnitedHealthcare often requires patients to "fail" less expensive treatments before covering specialty medications like Dojolvi.

Key Advantage: Florida law requires insurers to provide written procedures for protocol exemptions, including clear timelines and appeal rights—giving you specific tools to challenge denials.

UnitedHealthcare Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Dojolvi through OptumRx with strict criteria. Understanding these upfront helps avoid common denial reasons.

Coverage Requirements Table

Requirement What It Means Documentation Needed Source
Molecular Confirmation Pathogenic mutations in CPT2, ACADVL, HADHA, or HADHB genes Genetic testing results UHC PA Form
Specialist Prescriber Board-certified medical geneticist Physician credentials or consultation notes UHC PA Form
No Concurrent MCT Cannot use other medium-chain triglycerides Medication reconciliation UHC PA Form
Dosage Limits Maximum 35% of daily caloric intake Dietary management plan UHC PA Form
Clinical Evidence At least two diagnostic criteria Elevated acylcarnitines, low enzyme activity UHC PA Form

Common Denial Reasons and Fixes

Denial Reason How to Overturn Required Documentation
Missing genetic confirmation Submit pathogenic mutation results Lab reports showing CPT2, ACADVL, HADHA, or HADHB mutations
Non-specialist prescriber Provide consultation documentation Letter from board-certified medical geneticist
Concurrent MCT use Document discontinuation Updated medication list with stop dates
Insufficient clinical evidence Submit comprehensive testing Newborn screening results, acylcarnitine profiles, enzyme studies

Florida Step Therapy Protections and Medical Exceptions

Florida law provides powerful tools to bypass step therapy requirements when you have valid medical reasons. Under Florida Statute 627.42393, you can obtain a protocol exemption without completing prior steps if:

90-Day Prior Approval Exception

If you were approved for Dojolvi through another health plan within the past 90 days, UnitedHealthcare must grant an exception. Submit documentation showing:

  • Previous plan's approval
  • Payment confirmation within 90 days before your request
  • Continuous medical need

Medical Necessity Exceptions

Your physician can request an exception based on:

  • Contraindications to step therapy medications
  • Drug interactions with required first-line treatments
  • Previous failure or intolerance to alternative therapies
  • Urgent medical need where delays could cause harm
Clinician Corner: When writing medical necessity letters, cite specific clinical guidelines and include phrases like "medically contraindicated," "previous therapeutic failure," and "no suitable alternatives available." Reference the FDA-approved indication for LC-FAOD as the only approved therapy.

Continuity of Care During Plan Transitions

Florida requires continuity of care for medically stable patients during plan transitions, particularly important for rare disease medications. If you're switching to or from UnitedHealthcare:

Your Rights During Transitions

  • Coverage must continue for drugs prescribed for complex or chronic conditions
  • No interruption in therapy during the transition period
  • Protection against formulary changes that would disrupt ongoing treatment

Documentation to Maintain

  • Previous plan's approval letters
  • Clinical stability documentation
  • Physician attestation of medical necessity for continued therapy

Appeals Process: Internal and External Review

Florida's streamlined appeal process gives you multiple avenues to challenge UnitedHealthcare denials.

Internal Appeals Timeline

  • Standard Appeals: 30 days maximum (reduced from previous 47-day average)
  • Urgent Appeals: 72 hours for non-concurrent cases, 24 hours during active treatment
  • Filing Deadline: 180 days from denial notice

Step-by-Step Appeals Process

  1. Gather Documentation
    • Denial letter from UnitedHealthcare
    • Medical records supporting necessity
    • Genetic testing results
    • Physician's detailed letter
  2. Submit Internal Appeal
    • Use UnitedHealthcare Provider Portal or call 866-889-8054
    • Include all supporting documentation
    • Request expedited review if urgent
  3. External Review (If Internal Appeal Fails)
    • Request through Florida Department of Financial Services
    • Independent medical expert reviews your case
    • Decision is binding on UnitedHealthcare
    • No cost to you

Required Appeal Documentation

  • Complete medical records
  • Genetic testing confirming LC-FAOD diagnosis
  • Documentation of previous treatment failures (if applicable)
  • Physician letter explaining medical necessity
  • Evidence of specialist consultation

Practical Scripts for Calls and Appeals

Patient Phone Script for UnitedHealthcare

"Hello, I'm calling about a prior authorization denial for Dojolvi for long-chain fatty acid oxidation disorder. My member ID is [ID number]. I'd like to request an expedited internal appeal and speak with a supervisor about Florida's step therapy exception requirements under Statute 627.42393. Can you connect me with someone who handles rare disease appeals?"

Appeal Letter Template Opening

"I am formally appealing the denial of coverage for Dojolvi (triheptanoin) dated [date]. Under Florida Statute 627.42393, I am requesting a protocol exemption based on medical necessity. This medication is the only FDA-approved treatment for long-chain fatty acid oxidation disorders, and no suitable alternatives exist for my genetically confirmed condition."

When to File a State Complaint

Contact the Florida Department of Financial Services Consumer Helpline at 877-693-5236 if:

  • UnitedHealthcare exceeds Florida's 30-day appeal timeline
  • Your urgent appeal isn't processed within 72 hours
  • You face procedural violations during the appeals process
  • You need assistance navigating the external review process

You can also file complaints online through the Florida DFS portal.

Cost Assistance and Patient Support

Dojolvi's cost ranges from $5,857-$6,365 per 500-mL bottle, making financial assistance crucial:

Manufacturer Support

  • Ultragenyx Patient Services: Contact for copay assistance programs
  • Foundation grants: National Organization for Rare Disorders offers patient assistance

State Resources

  • Florida's rare disease patient assistance programs
  • Medicaid coverage for eligible patients

Counterforce Health specializes in helping patients navigate complex prior authorization requirements for specialty medications like Dojolvi. Their platform analyzes denial letters and creates targeted, evidence-backed appeals that address specific payer criteria, potentially saving weeks in the approval process. For families dealing with rare disease denials, having expert support can make the difference between prolonged treatment delays and timely access to life-saving therapy.

From Our Advocates: We've seen families successfully overturn Dojolvi denials by combining Florida's step therapy exception laws with comprehensive genetic documentation. One case involved a teenager whose initial denial was overturned within 48 hours after submitting an expedited appeal citing previous MCT treatment failures and urgent medical need. The key was having all molecular confirmation ready and emphasizing that Dojolvi is the only FDA-approved LC-FAOD therapy. This represents a composite of successful approaches, not a specific individual's experience.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Florida? Standard PA decisions must be made within 15 business days, but expedited reviews for urgent cases are completed within 72 hours under Florida law.

What if Dojolvi isn't on UnitedHealthcare's formulary? Non-formulary medications can still be covered through medical necessity appeals. Submit comprehensive documentation showing no suitable formulary alternatives exist.

Can I request an expedited appeal for Dojolvi? Yes, if delays could cause serious harm or if you're experiencing acute symptoms. Document the urgency in your appeal request.

Does step therapy apply if I failed treatments in another state? Florida's 90-day prior approval exception applies regardless of where previous treatment occurred. Submit documentation of prior failures or approvals.

What counts as molecular confirmation for LC-FAOD? Pathogenic mutations in genes including CPT2, ACADVL, HADHA, or HADHB, plus supporting evidence like elevated acylcarnitines or low enzyme activity.

How do I find a board-certified medical geneticist in Florida? Search the American Board of Medical Genetics directory or ask for referrals through your current physician.

What if my appeal is denied at all levels? After exhausting UnitedHealthcare's internal appeals and Florida's external review, you may have additional options through federal appeals processes or legal consultation.

Sources and Further Reading

For complex prior authorization challenges, Counterforce Health provides specialized support in creating evidence-backed appeals that address specific payer requirements, helping patients access critical medications more efficiently.

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. Florida insurance laws and UnitedHealthcare policies may change; verify current requirements through official sources.

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