By Counterforce Health Team in Fintepla (fenfluramine) —

Do You Qualify for Fintepla (Fenfluramine) Coverage by Aetna (CVS Health) in California? Decision Tree & Next Steps

Answer Box: Quick Qualification Check

To qualify for Fintepla (fenfluramine) coverage by Aetna (CVS Health) in California: You need a confirmed diagnosis of Dravet syndrome or Lennox-Gastaut syndrome (LGS) from a neurologist, documented failure of at least two standard antiseizure medications, enrollment in the FDA REMS program with baseline echocardiogram, and prior authorization approval. Fastest path: Have your neurologist submit Aetna's Global Prior Authorization Form with complete documentation. Start today: Contact your neurologist to gather treatment history and request REMS enrollment. If denied, California's Independent Medical Review (IMR) has a 73% success rate for specialty drug appeals.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Your Action Plan
  4. If "Possibly Eligible" - What You Need
  5. If "Not Yet" - Alternative Paths
  6. If Denied - California Appeal Options
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. FAQ: California-Specific Questions

How to Use This Decision Tree

This guide helps you determine if you qualify for Fintepla (fenfluramine) coverage through Aetna (CVS Health) in California and provides your next steps based on your situation. Work through the eligibility questions below, then follow the corresponding action plan.

Before you start, gather:

  • Insurance card and member ID
  • Complete list of seizure medications tried (names, doses, duration, outcomes)
  • Recent neurology consultation notes
  • EEG reports and genetic testing results (if available)
  • Any previous denial letters from Aetna

Eligibility Triage: Do You Qualify?

Primary Diagnosis Check ✓

Question 1: Do you have a confirmed diagnosis of Dravet syndrome or Lennox-Gastaut syndrome?

  • Dravet syndrome: Genetic epilepsy with SCN1A mutation (80% of cases), seizure onset before age 1, multiple seizure types including prolonged seizures often triggered by fever
  • Lennox-Gastaut syndrome: Childhood-onset epilepsy with ≥2 seizure types, EEG showing slow spike-and-wave discharges ≤2.5 Hz, cognitive impairment

If YES: Continue to Question 2 If NO: See "Not Yet" section

Treatment History Check ✓

Question 2: Have you tried and failed at least two standard antiseizure medications?

Required documentation includes medication names, doses, duration of trial, and specific reasons for discontinuation (lack of efficacy or intolerance).

If YES: Continue to Question 3 If NO: See "Possibly Eligible" section

REMS Program Check ✓

Question 3: Can you complete FDA REMS enrollment and required cardiac monitoring?

  • Baseline echocardiogram before starting treatment
  • Follow-up echocardiograms every 6 months during treatment
  • Both patient and prescriber must enroll in REMS program

If YES: You're likely eligible - proceed to action plan If UNSURE: See "Possibly Eligible" section

If "Likely Eligible" - Your Action Plan

Step-by-Step: Fastest Path to Approval

1. Confirm Your Aetna Plan Details (Day 1)

  • Call Aetna Member Services: 1-800-872-3862
  • Verify Fintepla is covered under your specific plan
  • Ask about formulary tier and any quantity limits
  • Request current prior authorization requirements

2. Schedule REMS Enrollment (Days 1-3)

  • Contact your neurologist to initiate Fintepla REMS enrollment
  • Schedule baseline echocardiogram
  • Both you and your prescriber must complete enrollment before prescription can be filled

3. Gather Required Documentation (Days 3-7)

  • Medical records confirming Dravet syndrome or LGS diagnosis
  • Complete antiseizure medication trial history with outcomes
  • Recent neurology consultation notes supporting Fintepla use
  • Baseline echocardiogram results

4. Submit Prior Authorization (Days 7-10)

5. Track Your Request (Days 10-15)

  • Aetna has 15-30 business days for standard review
  • For urgent cases, request expedited review (72-hour decision)
  • Call weekly for status updates and document reference numbers

Clinician Corner: Medical Necessity Letter Checklist

For Healthcare Providers: Your medical necessity letter should address:Specific diagnosis (ICD-10: G40.83 for Dravet, G40.81/G40.82 for LGS)Prior antiseizure medication trials with specific outcomesClinical rationale for Fintepla over alternativesPatient's current seizure frequency and impact on quality of lifeReference to FDA labeling and relevant clinical guidelines

If "Possibly Eligible" - What You Need

Missing Diagnosis Documentation

If you need formal diagnosis confirmation:

  • Schedule comprehensive epilepsy evaluation with neurologist
  • For Dravet syndrome: Request SCN1A genetic testing
  • For LGS: Ensure EEG documentation of slow spike-and-wave patterns
  • Timeline: 4-8 weeks for complete workup

Insufficient Treatment History

If you need more antiseizure medication trials:

  • Work with your neurologist to document previous treatments thoroughly
  • Consider trials of standard first-line agents appropriate for your syndrome
  • Each trial should be at therapeutic doses for adequate duration (typically 2-3 months)
  • Timeline: 6-12 months depending on treatments needed

REMS Program Concerns

If cardiac monitoring is a concern:

  • Discuss with cardiologist if you have existing heart conditions
  • Baseline echo is required regardless of cardiac history
  • UCB's ONWARD Patient Support Program may help with monitoring costs

If "Not Yet" - Alternative Paths

Diagnosis Not Yet Confirmed

Consider these steps:

  • Seek second opinion from epilepsy specialist at comprehensive epilepsy center
  • Request genetic counseling for suspected Dravet syndrome
  • Explore other treatment options while pursuing diagnosis clarification

Alternative Treatments to Discuss

While working toward Fintepla approval, discuss these FDA-approved options with your neurologist:

  • Dravet syndrome: Cannabidiol (Epidiolex), stiripentol (Diacomit), clobazam
  • LGS: Cannabidiol (Epidiolex), rufinamide (Banzel), felbamate, lamotrigine

Preparing for Exception Requests

If standard criteria aren't met, prepare for formulary exception:

  • Document why standard treatments are inappropriate
  • Gather evidence of unique clinical circumstances
  • Consider compassionate use or patient assistance programs

If Denied - California Appeal Options

California offers robust appeal rights with high success rates for specialty medications. Here's your pathway:

Level 1: Aetna Internal Appeal (60 days to file)

Standard Process:

  • File within 60 days of denial notice
  • Submit additional clinical documentation
  • Request peer-to-peer review with Aetna medical director
  • Decision timeline: 30 days (72 hours for urgent cases)

Contact Information:

  • Phone: 1-855-582-2025
  • Appeals address: (verify current address with member services)

Level 2: California Independent Medical Review (IMR)

Why IMR is powerful for Fintepla appeals:

  • 73% success rate for specialty drug appeals (vs. 12-13% for all services)
  • Independent medical experts review your case
  • Decision is binding on Aetna
  • No cost to you - Aetna pays all review fees

IMR Process:

  • File within 180 days of Aetna's final denial
  • Submit through DMHC online portal or call 888-466-2219
  • Standard timeline: 30-45 days (72 hours for urgent cases)
  • Include comprehensive medical records and specialist letters
From our advocates: "We've seen multiple Fintepla denials overturned at California IMR when families submitted complete REMS documentation and detailed seizure logs showing inadequate control with prior medications. The key is demonstrating clear medical necessity with objective evidence."

When to Request Expedited Review:

  • Frequent, life-threatening seizures
  • Significant deterioration in seizure control
  • Risk of status epilepticus

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all Aetna plans Aetna Precertification List
Diagnosis Dravet syndrome (G40.83) or LGS (G40.81/G40.82) Aetna Policy
Prescriber Neurologist or epilepsy specialist Aetna Policy
Step Therapy ≥2 prior antiseizure medications documented Aetna Policy
REMS Enrollment Patient and prescriber must enroll FDA REMS
Cardiac Monitoring Baseline and q6mo echocardiograms FDA Label
Decision Timeline 15-30 days standard, 72 hours expedited Aetna Policy

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing REMS enrollment Complete enrollment before resubmission REMS confirmation + baseline echo
Insufficient step therapy Document additional failed trials Detailed medication history with outcomes
Diagnosis not supported Provide specialist confirmation Neurology notes + genetic/EEG reports
Non-formulary status Request formulary exception Medical necessity letter citing guidelines
Experimental/investigational Cite FDA approval and guidelines FDA label + clinical evidence

FAQ: California-Specific Questions

Q: How long does Aetna prior authorization take in California? A: Standard review takes 15-30 business days. Expedited review for urgent medical needs takes 72 hours. You can request expedited review if delays would seriously jeopardize your health.

Q: What if Fintepla is not on my Aetna formulary? A: Request a formulary exception through your prescriber. Provide medical necessity documentation showing why formulary alternatives are inappropriate. California law supports access to non-formulary medications when medically necessary.

Q: Can I appeal to California if Aetna denies my request? A: Yes. California's Independent Medical Review (IMR) has a 73% success rate for specialty drug appeals. File through the DMHC website within 180 days of Aetna's final denial.

Q: Does step therapy apply if I failed medications outside California? A: Yes. Aetna recognizes medication trials from any location with proper documentation. Ensure your previous neurologist provides detailed records of each trial.

Q: What financial assistance is available for Fintepla in California? A: UCB's ONWARD Patient Support Program offers copay assistance with most eligible patients paying $0-25. Additional foundation grants may be available for uninsured patients.

Q: Who can help me navigate the appeals process in California? A: Contact the DMHC Help Center at 888-466-2219. They provide free assistance with filing complaints and IMR applications. Health Consumer Alliance also offers support for complex cases.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform streamlines the prior authorization process by identifying denial reasons and drafting point-by-point rebuttals aligned to each plan's specific requirements. For families navigating complex specialty drug approvals like Fintepla, Counterforce Health provides the clinical documentation and appeal strategies that improve approval odds.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with California insurance appeals, contact the DMHC Help Center at 888-466-2219.

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