How to Get Dojolvi (Triheptanoin) Covered by UnitedHealthcare in Ohio: Complete Resource Guide
Quick Answer: Getting Dojolvi Covered by UnitedHealthcare in Ohio
To get Dojolvi (triheptanoin) approved by UnitedHealthcare in Ohio: Submit a prior authorization through the UHC Provider Portal or fax 866-940-7328 with genetic testing confirming LC-FAOD, prescription from a board-certified medical geneticist, and documentation that no MCT products are being used concurrently. If denied, you have 180 days for internal appeals, then 180 days for Ohio external review through the Department of Insurance (1-800-686-1526). Start today: Verify your plan's formulary status and gather genetic test results.
Table of Contents
- Verify Your Plan & Find the Right Forms
- Required Prior Authorization Forms
- Submission Portals & Methods
- Specialty Pharmacy Setup & Transfers
- Support Phone Numbers & Case Management
- Ohio Appeals Process & External Review
- Common Denial Reasons & Solutions
- When to Update Your Resources
1. Verify Your Plan & Find the Right Forms
Before starting your Dojolvi prior authorization, confirm your specific UnitedHealthcare plan type and formulary status. Different UHC plans (commercial, Medicare Advantage, Medicaid managed care) may have varying requirements.
Check Your Plan Details:
- Log into myuhc.com or call the member services number on your ID card
- Verify if Dojolvi requires prior authorization (PA) for your specific plan
- Confirm your plan uses OptumRx for specialty pharmacy benefits
Tip: Most UnitedHealthcare plans require PA for Dojolvi due to its specialty medication status and high cost (typically $5,857–$6,365 per 500-mL bottle).
2. Required Prior Authorization Forms
UnitedHealthcare requires specific documentation for Dojolvi approval. The current policy (effective August 1, 2025) has strict medical necessity criteria.
Coverage Requirements at a Glance
| Requirement | Details | Documentation Needed |
|---|---|---|
| Diagnosis | Long-chain fatty acid oxidation disorder (LC-FAOD) | Genetic testing or biochemical confirmation |
| Prescriber | Board-certified medical geneticist experienced in LC-FAOD | Provider credentials and specialty verification |
| No MCT Use | Cannot use Dojolvi with other medium-chain triglyceride products | Medication reconciliation form |
| Dosage Limit | Maximum 35% of total daily caloric intake | Dietary management plan |
| Authorization Period | 12 months initial, 12 months renewal | Clinical response documentation for renewal |
Required Medical Documentation:
- Genetic testing results showing pathogenic mutations (CPT2, ACADVL, HADHA, HADHB genes)
- Elevated acylcarnitines on newborn screening or plasma blood spot
- Low enzyme activity in cultured fibroblasts (if applicable)
- Clinical history of LC-FAOD manifestations (e.g., rhabdomyolysis)
- Current dietary management plan
- Confirmation no other MCT products are prescribed
Access the official UnitedHealthcare Dojolvi prior authorization forms through the UHC Provider Portal under "Prior Authorization" > "Pharmacy" > "Dojolvi."
3. Submission Portals & Methods
Electronic Submission (Preferred)
UnitedHealthcare Provider Portal: Most efficient method for PA submissions and status tracking. Requires One Healthcare ID registration.
Fax Submissions
- General Prior Authorization: 866-940-7328
- Pharmacy Prior Authorization: 877-940-1972
- OptumRx Specialty: 855-427-4682
Required Cover Sheet Information
Include on all fax submissions:
- Patient name and UHC member ID
- Provider NPI and contact information
- "URGENT: Dojolvi Prior Authorization - LC-FAOD"
- Complete page count
Note: Electronic submissions through the provider portal typically process faster and allow real-time status tracking.
4. Specialty Pharmacy Setup & Transfers
Dojolvi is typically dispensed through UnitedHealthcare's preferred specialty pharmacy network. If you're switching from another plan or pharmacy, coordinate the transfer carefully to avoid treatment interruption.
Specialty Pharmacy Contact
UnitedHealthcare Specialty Pharmacy Services: 1-855-427-4682 (24/7)
Transfer Process
- Verify Network Status: Confirm your preferred specialty pharmacy is in-network using the provider directory at myuhc.com
- Request Transfer: Call 1-855-427-4682 to initiate prescription transfer
- Submit Forms: Complete Transition of Care forms if switching plans (available in English and Spanish)
- Coordinate Timing: Ensure sufficient medication supply during transfer period
For urgent medication needs during transitions, request expedited processing through the specialty pharmacy service line.
5. Support Phone Numbers & Case Management
Key Contact Numbers
| Service | Phone Number | Best For |
|---|---|---|
| Specialty Pharmacy & Case Management | 1-855-427-4682 | Dojolvi transfers, urgent reviews, supply issues |
| General Prior Authorization | 800-310-6826 | PA status checks, general questions |
| Member Services | Number on your ID card | Plan-specific coverage questions |
| Ohio Department of Insurance | 1-800-686-1526 | Appeals assistance, external review |
What to Ask When Calling
- Request your PA reference number for tracking
- Ask for expected timeline for determination
- Confirm all required documents were received
- Request expedited review if clinically urgent
6. Ohio Appeals Process & External Review
If your Dojolvi prior authorization is denied, Ohio provides strong consumer protections through its appeals process.
Internal Appeals with UnitedHealthcare
Timeline: Must submit within 12 months of denial Process:
- Submit reconsideration request through UHC Provider Portal or fax
- Include additional clinical documentation addressing denial reasons
- Request peer-to-peer review with medical director if appropriate
Ohio External Review Process
After exhausting internal appeals, you can request an independent external review.
Key Details:
- Timeline: 180 days from final UHC denial
- Cost: Free to consumers
- Process: Independent Review Organization (IRO) reviews your case
- Decision: Binding on UnitedHealthcare if approved
How to Request External Review:
- Contact your health plan to request external review forms
- Submit written request with medical records release authorization
- If UHC rejects your request, appeal directly to Ohio Department of Insurance
- Call 1-800-686-1526 for assistance with the process
Important: Ohio law allows the Department of Insurance to override insurer determinations about external review eligibility.
7. Common Denial Reasons & Solutions
Understanding typical denial reasons helps you prepare stronger initial submissions and appeals.
Frequent Denial Reasons & Fixes
| Denial Reason | Solution | Required Documentation |
|---|---|---|
| Insufficient genetic confirmation | Submit comprehensive genetic testing | Pathogenic mutations in LC-FAOD genes |
| Concurrent MCT use | Discontinue other MCT products | Updated medication list, prescriber attestation |
| Non-specialist prescriber | Transfer prescription to medical geneticist | Board certification verification |
| Exceeds dosage limits | Adjust to ≤35% daily caloric intake | Revised dietary management plan |
| Lack of clinical response (renewal) | Document improvement metrics | Cardiac function tests, rhabdomyolysis frequency |
Medical Necessity Letter Checklist
When appealing, ensure your medical necessity letter includes:
- Specific LC-FAOD diagnosis with genetic confirmation
- Failed or contraindicated alternative therapies
- Clinical rationale for Dojolvi specifically
- Dosing justification within policy limits
- Monitoring plan and expected outcomes
- Citations to FDA labeling and clinical guidelines
8. When to Update Your Resources
Healthcare policies and forms change regularly. Stay current with these practices:
Quarterly Checks:
- Review UnitedHealthcare formulary updates
- Verify current PA forms and submission methods
- Check for Ohio regulatory changes
Before Each Submission:
- Confirm current fax numbers and portal URLs
- Review latest UHC Dojolvi policy (check effective dates)
- Verify specialty pharmacy network status
Annual Reviews:
- Update provider portal access credentials
- Review plan benefits and coverage changes
- Confirm Ohio external review procedures
From Our Advocates
In our experience helping families navigate LC-FAOD treatment approvals, the most successful applications combine genetic testing results with detailed clinical history and a clear dietary management plan. One key insight: medical geneticists familiar with the UnitedHealthcare criteria often streamline approvals by addressing all policy requirements upfront, reducing the need for additional documentation requests.
Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Dojolvi. Our platform analyzes denial letters and payer policies to craft point-by-point rebuttals that align with each insurer's specific requirements, helping patients and clinicians navigate the prior authorization maze more effectively. Learn more about our services.
When facing a Dojolvi denial from UnitedHealthcare, having the right documentation and understanding Ohio's appeals process can make the difference between approval and prolonged treatment delays. Counterforce Health helps streamline this process by identifying denial patterns and crafting targeted responses that address payer-specific criteria.
Frequently Asked Questions
How long does UnitedHealthcare prior authorization take for Dojolvi in Ohio? Standard PA reviews typically take 3-5 business days. Urgent reviews (for immediate medical need) may be processed within 24-72 hours.
What if Dojolvi isn't on my UnitedHealthcare formulary? Non-formulary medications can still be covered through medical necessity exceptions. Submit PA documentation emphasizing the lack of therapeutic alternatives for LC-FAOD.
Can I request an expedited appeal in Ohio? Yes. Expedited reviews are available when delays would seriously endanger your health. Request expedited processing when submitting appeals.
Does UnitedHealthcare step therapy apply to Dojolvi? Due to the lack of alternative FDA-approved LC-FAOD treatments, traditional step therapy doesn't apply. However, you must demonstrate proper diagnosis and prescriber qualifications.
What happens if my Ohio external review is denied? While external review decisions are binding on the insurer, you retain rights to seek other remedies including regulatory complaints or legal action.
How do I transfer Dojolvi prescriptions between specialty pharmacies? Call UnitedHealthcare Specialty Pharmacy Services at 1-855-427-4682 to coordinate transfers and ensure continuous medication supply.
Sources & Further Reading
- UnitedHealthcare Dojolvi Prior Authorization Policy (PDF)
- Ohio Department of Insurance External Review Process
- UnitedHealthcare Provider Portal Resources
- Ohio Health Coverage Appeals Guide
- FDA Dojolvi Prescribing Information
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may vary by plan and change over time. Always consult your healthcare provider and review your specific insurance policy documents. For personalized assistance with Ohio health insurance appeals, contact the Ohio Department of Insurance Consumer Hotline at 1-800-686-1526.
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