By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by UnitedHealthcare in Michigan: Complete PA Guide with Appeal Scripts

Answer Box: Getting Dojolvi Covered by UnitedHealthcare in Michigan

Dojolvi (triheptanoin) requires prior authorization from UnitedHealthcare for long-chain fatty acid oxidation disorders (LC-FAOD). Key requirements: molecular genetic confirmation of LC-FAOD, prescription from a board-certified medical geneticist, no concurrent MCT products, and dosing ≤35% of daily calories. First step: Download the UnitedHealthcare Dojolvi PA form and gather genetic testing results. If denied, Michigan residents have 127 days to file external review with Michigan DIFS.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Dojolvi prescriptions UnitedHealthcare PA notification
Molecular Confirmation Genetic testing showing pathogenic mutations in CPT2, ACADVL, HADHA, or HADHB genes UnitedHealthcare medical necessity criteria
Prescriber Qualification Board-certified medical geneticist experienced with LC-FAOD Same as above
Dosage Limit ≤35% of total daily caloric intake Same as above
No Concurrent MCT Cannot use with other medium-chain triglyceride products Same as above
Authorization Duration 12 months (initial and renewals) Same as above

Step-by-Step: Fastest Path to Approval

1. Verify Your UnitedHealthcare Plan Coverage

Who: Patient or clinic staff
Action: Log into UnitedHealthcare member portal or call the number on your insurance card
Timeline: Same day
What to ask: "Is Dojolvi covered under my pharmacy or medical benefit? What's my specialty medication copay?"

2. Gather Required Documentation

Who: Medical geneticist and clinic staff
Documents needed:

  • Genetic testing results confirming LC-FAOD
  • Clinical history and manifestations (if not diagnosed via newborn screening)
  • Current dietary management plan
  • Confirmation that other MCT products have been discontinued

3. Complete Prior Authorization Form

Who: Prescribing physician
Form: UnitedHealthcare Dojolvi Medical Necessity Form
Timeline: Allow 2-3 business days for completion
Key sections: Diagnosis confirmation, genetic testing results, prescriber credentials

4. Submit Prior Authorization

How: UnitedHealthcare provider portal or fax to 866-940-7328
Timeline: Submit 5-7 business days before medication is needed
Follow-up: Check status via provider portal after 3-5 business days

5. If Approved: Set Up Specialty Pharmacy

Contact: Optum Specialty Pharmacy at 1-855-427-4682
Process: Medication will be shipped directly to patient
Timeline: 3-5 business days for first shipment

6. If Denied: File Internal Appeal

Timeline: Within 60 days of denial notice
How: UnitedHealthcare appeals section in provider portal or mail to:
P.O. Box 31364, Salt Lake City, UT 84131-0364

7. If Still Denied: Michigan External Review

Timeline: Within 127 days of final internal denial
How: Michigan DIFS external review form
Support: Call Michigan DIFS at 877-999-6442

Required Forms and Documentation

Primary Forms

Supporting Documentation Checklist

  • Genetic testing report showing pathogenic mutations
  • Medical records confirming LC-FAOD diagnosis
  • Prescriber's board certification in medical genetics
  • Current dietary management plan
  • Documentation of discontinued MCT products
  • Clinical history (rhabdomyolysis episodes, cardiac issues)
  • Lab results (acylcarnitines, enzyme activity)

Submission Portals and Contact Information

Online Portals

  • Provider Portal: uhcprovider.com (requires One Healthcare ID)
  • Member Portal: Available through UnitedHealthcare member website
  • PA Status Check: Available in both provider and member portals

Key Contact Numbers

Service Phone Fax
Prior Authorization 800-310-6826 866-940-7328
Optum Specialty Pharmacy 1-855-427-4682 800-853-3844
Provider Services 877-842-3210 N/A
Member Services Number on insurance card N/A

Mailing Addresses

Appeals: P.O. Box 31364, Salt Lake City, UT 84131-0364
Urgent Appeals Fax: 801-994-1261, 888-808-9123, or 866-373-1081 (verify region-specific number)

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing molecular confirmation Submit genetic testing results Pathogenic mutation report for CPT2, ACADVL, HADHA, or HADHB
Concurrent MCT use Document discontinuation Physician attestation of MCT product cessation
Unqualified prescriber Transfer care or consultation Board certification in medical genetics
Exceeds dosage limits Adjust prescription Dietary plan showing ≤35% of daily calories
Insufficient clinical history Provide detailed records Episodes of rhabdomyolysis, cardiac issues, metabolic crises
From Our Advocates: We've seen cases where initial denials were overturned simply by providing the genetic testing report in the correct format. Some labs use different terminology, so ensure the report clearly states "pathogenic mutation" rather than just "variant of uncertain significance."

Appeals Process in Michigan

Internal Appeals (UnitedHealthcare)

Timeline: 60 days from denial notice to file
Response time: 60 days for post-service, 15 days for pre-service
How to file: Provider portal, mail, or fax using addresses above

External Review (Michigan DIFS)

Timeline: 127 days from final internal denial
Cost: Free to patients
Process: DIFS assigns to Independent Review Organization (IRO)
Decision timeline: 60 days standard, 72 hours expedited
Binding: Yes, UnitedHealthcare must comply with favorable decisions

Expedited Review

When available: Serious jeopardy to health or life
Required: Physician letter stating urgency
Timeline: 72 hours for decision

Michigan DIFS Contact:

Specialty Pharmacy Setup

Dojolvi is typically dispensed through specialty pharmacies due to its specialized handling requirements and high cost (approximately $5,857-$6,365 per 500-mL bottle).

Optum Specialty Pharmacy Process

  1. Enrollment: Call 1-855-427-4682 after PA approval
  2. Medication transfer: Provide current pharmacy information
  3. Delivery setup: Choose delivery schedule and location
  4. Refill management: Automatic refill reminders and coordination
  5. Clinical support: Access to pharmacists specializing in metabolic disorders

What to Expect

  • First shipment: 3-5 business days after enrollment
  • Temperature control: Medications shipped with temperature monitoring
  • Insurance coordination: Direct billing to UnitedHealthcare
  • 24/7 support: Available for urgent questions or issues

Cost Savings and Financial Assistance

Manufacturer Support

Ultragenyx Patient Services: Visit the Dojolvi manufacturer website for current patient assistance programs and copay support options.

Additional Resources

  • State pharmaceutical assistance: Michigan may offer programs for rare disease medications
  • Foundation grants: Organizations like the National Organization for Rare Disorders (NORD) provide assistance
  • Hospital financial counseling: Many medical centers have specialists for rare disease coverage

FAQ

Q: How long does UnitedHealthcare prior authorization take for Dojolvi?
A: Standard PA decisions are made within 15 days for pre-service requests. Urgent requests may be processed within 72 hours with appropriate clinical justification.

Q: What if my child was diagnosed with LC-FAOD but genetic testing wasn't done?
A: UnitedHealthcare requires molecular confirmation. Work with your medical geneticist to order appropriate genetic testing, which typically includes sequencing of CPT2, ACADVL, HADHA, and HADHB genes.

Q: Can I appeal if I'm already taking Dojolvi and UnitedHealthcare stops covering it?
A: Yes. This would be considered a reduction in benefits, and you can file an internal appeal followed by Michigan external review if necessary. Document your positive clinical response to support continued coverage.

Q: Does step therapy apply to Dojolvi in Michigan?
A: UnitedHealthcare's current policy doesn't require trying other therapies first for molecularly confirmed LC-FAOD, as Dojolvi is the only FDA-approved treatment for this condition.

Q: What happens if I miss the 127-day deadline for external review?
A: You lose your right to external review through Michigan DIFS. However, you may still have options through other regulatory complaints or legal channels. Contact DIFS immediately if you're approaching the deadline.

Q: Can my pediatrician prescribe Dojolvi, or does it have to be a medical geneticist?
A: UnitedHealthcare specifically requires prescription by a board-certified medical geneticist experienced with LC-FAOD. Your pediatrician can refer you to an appropriate specialist.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Dojolvi. Our platform analyzes denial letters and payer policies to create targeted, evidence-backed appeals that address specific coverage criteria. We help patients, clinicians, and specialty pharmacies navigate the complex prior authorization landscape with higher approval rates and faster resolutions.

For additional support with UnitedHealthcare coverage challenges, Counterforce Health provides tools and expertise to strengthen your appeal with payer-specific documentation and clinical evidence that meets UnitedHealthcare's exact requirements.

Sources and Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with healthcare providers or insurance professionals. Coverage policies and procedures may change. Always verify current requirements with UnitedHealthcare and consult with your medical team for treatment decisions. For official Michigan insurance regulations and consumer assistance, contact Michigan DIFS at 877-999-6442.

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