By Counterforce Health Team in Dojolvi (triheptanoin) —

Lowering Out-of-Pocket for Dojolvi (Triheptanoin) with Blue Cross Blue Shield in North Carolina: Copay, Tiering & Assistance

Answer Box: Getting Dojolvi Covered by Blue Cross Blue Shield in North Carolina

Fastest path to approval: Submit prior authorization through your prescriber with molecular confirmation of LC-FAOD, detailed medical necessity letter, and documentation of failed alternatives. Blue Cross NC requires PA for Dojolvi (Tier 5 specialty). If denied, appeal internally within 180 days, then request external review through Smart NC (42% overturn rate). First step today: Call Blue Cross member services to confirm your specific formulary tier and PA requirements.

Table of Contents

  1. What Drives Dojolvi Costs with Blue Cross Blue Shield
  2. Benefit Investigation: What to Ask Your Plan
  3. Assistance Options: Copay Programs and Foundations
  4. Requesting Tiering Exceptions
  5. Specialty Pharmacy Coordination
  6. Appeals on Cost Grounds
  7. Annual Renewal Planning
  8. Conversation Scripts
  9. Common Denial Reasons & Solutions
  10. North Carolina External Review Process
  11. FAQ

What Drives Dojolvi Costs with Blue Cross Blue Shield

Understanding your benefit design is the first step to managing Dojolvi's substantial costs—with cash prices ranging from $5,857–$6,365 per 500-mL bottle.

Coverage Basics

Blue Cross Blue Shield of North Carolina typically places Dojolvi on Tier 5 (specialty tier), requiring prior authorization and higher cost-sharing than standard medications. Your specific costs depend on:

  • Plan type: Commercial, marketplace, or Medicare
  • Deductible status: Whether you've met your annual deductible
  • Coinsurance vs. copay: Percentage-based or flat-fee structure
  • Out-of-pocket maximum: Your annual spending cap
Note: Blue Cross NC contracts with Prime Therapeutics for pharmacy benefit management, so PA criteria may reference Prime's policies.

Tiering Impact on Costs

Tier Level Typical Cost-Sharing Example Monthly Cost
Tier 1 (Generic) $10-25 copay N/A (no generic)
Tier 2 (Preferred Brand) $40-75 copay N/A
Tier 3 (Non-preferred Brand) 25-40% coinsurance $1,500-2,500
Tier 5 (Specialty) 30-50% coinsurance $1,750-3,200

Benefit Investigation: What to Ask Your Plan

Before your prescriber submits the PA, gather specific benefit details to avoid surprises.

Essential Questions for Blue Cross NC

Call the member services number on your insurance card and ask:

  1. "Is Dojolvi (triheptanoin) covered on my formulary?"
    • Record the tier level and any restrictions
  2. "What's my exact cost-sharing for Tier 5 specialty drugs?"
    • Get dollar amounts, not just percentages
  3. "Do I need to meet my deductible first?"
    • Confirm if specialty drugs are subject to deductible
  4. "What's the prior authorization process?"
    • Ask for forms and submission methods
  5. "Are there quantity limits or step therapy requirements?"
    • Document any restrictions

Information to Record

  • Policy/Group number
  • Pharmacy benefit manager: Usually Prime Therapeutics for Blue Cross NC
  • Specialty pharmacy network: Required dispensing locations
  • PA form names/numbers
  • Submission deadlines

Assistance Options: Copay Programs and Foundations

Multiple programs can significantly reduce your out-of-pocket costs for Dojolvi.

Ultragenyx Copay Assistance Program

Eligibility: Commercial insurance required (no Medicare/Medicaid)

Important: Government insurance beneficiaries cannot use manufacturer copay assistance due to federal anti-kickback regulations.

Foundation Grants for LC-FAOD

PAN Foundation

FOD Family Support Group

Free Genetic Testing

Invitae LC-FAOD Program offers no-charge genetic testing for suspected LC-FAOD patients in the US and Canada, removing diagnostic cost barriers.

Requesting Tiering Exceptions

If Dojolvi is non-formulary or on a high tier, you can request an exception to lower your costs.

When to Request an Exception

  • Non-formulary status: Drug not covered at all
  • High tier placement: Dojolvi on Tier 5 when you need Tier 2-3 pricing
  • Step therapy requirements: Mandated trial of ineffective alternatives

Exception Request Process

  1. Initiate request: Your prescriber submits through Blue Cross NC provider portal or by fax
  2. Medical necessity documentation: Detailed letter explaining why alternatives are inappropriate
  3. Clinical evidence: Lab results, genetic testing, prior treatment failures
  4. Review timeline: 72 hours for standard requests, 24 hours for urgent cases

Required Documentation

Your prescriber should include:

  • Confirmed LC-FAOD diagnosis with molecular/biochemical evidence
  • Prior therapy failures: MCT oil, carnitine, dietary modifications
  • Contraindications: Why standard alternatives won't work
  • Treatment goals: Specific outcomes expected with Dojolvi

Specialty Pharmacy Coordination

Dojolvi requires specialty pharmacy dispensing, which affects both costs and logistics.

Blue Cross NC Specialty Network

  • In-network specialty pharmacies: Lower cost-sharing
  • Out-of-network penalties: Significantly higher costs or no coverage
  • Prior authorization: Must be approved before specialty pharmacy can dispense

Coordination Tips

  1. Verify network status: Confirm your preferred specialty pharmacy is in-network
  2. Coordinate with UltraCare: Let them handle pharmacy setup and insurance verification
  3. Plan for shipping: Allow 3-5 business days for delivery
  4. Temperature requirements: Ensure proper storage upon arrival
Tip: UltraCare can often coordinate directly with Blue Cross NC's contracted specialty pharmacies to streamline the process.

Appeals on Cost Grounds

If your initial PA is approved but costs remain unaffordable, you can appeal the tier placement or cost-sharing decision.

Internal Appeal Process

Timeline: 180 days from denial or adverse determination

Steps:

  1. Submit written appeal to Blue Cross NC appeals department
  2. Include financial hardship documentation if relevant
  3. Request peer-to-peer review with medical director
  4. Await decision: 30 days for standard, 72 hours for expedited

Required Documentation

  • Original denial letter
  • Updated medical necessity letter
  • Financial hardship evidence (if applicable)
  • Comparable therapy costs showing Dojolvi is cost-effective

Annual Renewal Planning

Plan changes can affect your Dojolvi coverage each year.

What Can Change

  • Formulary tier: Dojolvi could move to different tier
  • PA requirements: Criteria may become more or less restrictive
  • Network pharmacies: Specialty pharmacy options may change
  • Cost-sharing: Deductibles, coinsurance rates can adjust

Renewal Checklist

October-November:

  • Review next year's formulary for Dojolvi placement
  • Check specialty pharmacy network changes
  • Confirm PA requirements for continuation

December:

  • Submit any needed documentation for coverage continuation
  • Coordinate with UltraCare for seamless transition

January:

  • Verify first prescription of new plan year processes smoothly
  • Confirm copay assistance program renewal

Conversation Scripts

Blue Cross NC Member Services Script

"Hi, I need to verify coverage details for Dojolvi, spelled D-O-J-O-L-V-I, for long-chain fatty acid oxidation disorder. Can you tell me:

  • What tier is it on my formulary?
  • What's my exact cost-sharing for specialty drugs?
  • Do I need prior authorization?
  • What specialty pharmacies are in-network?"

Prescriber Office Script

"I need help with the Dojolvi prior authorization for Blue Cross NC. The PA should include:

  • My confirmed LC-FAOD diagnosis with genetic testing
  • Documentation of failed MCT therapy
  • Medical necessity for the specific dosing prescribed
  • Can you also request a peer-to-peer if initially denied?"

UltraCare Support Script

"I'm a Blue Cross NC member who needs Dojolvi coverage. Can you help with:

  • Benefits investigation for my specific plan
  • Copay assistance program enrollment
  • Specialty pharmacy coordination
  • PA support if needed?"

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Missing molecular confirmation Submit genetic testing results Lab reports showing LC-FAOD mutations
Concurrent MCT use Document discontinuation Provider attestation of MCT cessation
Lack of specialist involvement Get metabolic specialist evaluation Referral to genetic metabolic specialist
Insufficient prior failures Document tried therapies Treatment history with outcomes
Quantity limits exceeded Request exception based on weight/age Dosing calculation worksheet

North Carolina External Review Process

If Blue Cross NC denies your appeal, North Carolina's external review offers a final chance for coverage.

Smart NC External Review

Success rate: 42% overall overturn rate, higher for rare disease drugs with strong documentation

Eligibility:

  • Exhausted all Blue Cross NC internal appeals
  • State-regulated plan (not self-funded employer plans)
  • Medical necessity or experimental treatment denial

Process:

  1. Submit request to Smart NC within 120 days
  2. Provide documentation: All medical records, denial letters, clinical evidence
  3. IRO review: Independent medical review within 45 days (72 hours for expedited)
  4. Binding decision: Blue Cross NC must comply with favorable ruling

Smart NC Contact Information

FAQ

Q: How long does Blue Cross NC prior authorization take for Dojolvi? A: Standard PA decisions are made within 72 hours. Urgent requests (when delay would jeopardize health) are processed within 24 hours.

Q: What if Dojolvi is non-formulary on my Blue Cross NC plan? A: You can request a formulary exception with medical necessity documentation. Success depends on demonstrating that covered alternatives are inappropriate for your LC-FAOD.

Q: Can I get expedited appeals in North Carolina? A: Yes, both Blue Cross NC internal appeals and Smart NC external reviews offer expedited processing for urgent medical situations, typically within 72 hours.

Q: Does step therapy apply if I've tried therapies outside North Carolina? A: Medical records from any state showing failed therapies should count toward step therapy requirements. Ensure your prescriber includes all prior treatment documentation.

Q: What's the difference between a PA denial and a coverage denial? A: PA denial means the request for coverage was rejected. Coverage denial means the drug isn't covered at all. Both can be appealed, but coverage denials may require formulary exception requests.

Q: Can I use manufacturer copay assistance with Medicare? A: No, federal regulations prohibit manufacturer copay assistance for government insurance beneficiaries, including Medicare and Medicaid.

From our advocates: "One family successfully overturned a Blue Cross NC denial by working with their metabolic specialist to document how Dojolvi's unique anaplerotic mechanism was essential for their child's LC-FAOD management, something MCT oil couldn't provide. The key was specific biochemical evidence showing why alternatives were medically inappropriate."

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals for prescription drugs. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements, improving approval rates for complex medications like Dojolvi.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For additional help with insurance appeals in North Carolina, contact Smart NC at 1-855-408-1212.

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