By Counterforce Health Team in Fintepla (fenfluramine) —

Get Fintepla (Fenfluramine) Covered by Blue Cross Blue Shield in New Jersey: Prior Authorization, Appeals & Cost Help

Answer Box: Fintepla Coverage with Blue Cross Blue Shield in New Jersey

To get Fintepla (fenfluramine) covered by Blue Cross Blue Shield in New Jersey, you'll need prior authorization with clinical documentation proving Dravet syndrome or Lennox-Gastaut syndrome diagnosis. Most families pay $0-25 with UCB's copay card if commercially insured. If denied, New Jersey's external appeal process through Maximus gives you strong rights to independent medical review within 45 days.

Start today: Call BCBS member services to request the prior authorization form, gather your child's seizure records, and enroll in UCB's ONWARD copay program at 1-833-463-7547.

Table of Contents

  1. Understanding Your Coverage Basics
  2. Prior Authorization Requirements
  3. Cost Reduction Strategies
  4. When Coverage Gets Denied
  5. New Jersey's External Appeal Rights
  6. Clinician Resources
  7. Common Questions

Understanding Your Coverage Basics

Horizon Blue Cross Blue Shield of New Jersey covers Fintepla on their 2024 formularies, but it's classified as a specialty tier medication requiring prior authorization. This means higher copays than regular prescriptions—often 25-40% coinsurance instead of a flat $10-30 copay.

The good news? Most families with commercial insurance end up paying very little thanks to manufacturer assistance programs we'll cover below.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Must prove medical necessity before coverage BCBS NJ Provider Portal
Specialty Tier Higher out-of-pocket costs (25-40% coinsurance) Your plan's Summary of Benefits
Age Restriction FDA-approved for ages 2+ FDA Label
Diagnosis Codes G40.83 (Dravet), G40.82 (LGS) required Medical records from neurologist
REMS Program Mandatory cardiac monitoring enrollment Fintepla REMS

Prior Authorization Requirements

Blue Cross Blue Shield requires comprehensive documentation before approving Fintepla. Here's what your neurologist needs to submit:

Required Documentation Checklist

  • Confirmed diagnosis of Dravet syndrome or Lennox-Gastaut syndrome with supporting genetic testing (for Dravet) or EEG findings
  • Patient age verification (must be 2 years or older)
  • Prior therapy documentation showing inadequate response to at least 2-3 standard anti-seizure medications
  • REMS enrollment confirmation with baseline echocardiogram results
  • Current seizure frequency and functional impact assessment
  • Prescriber attestation of medical necessity
Tip: Many denials happen because the prior authorization form is incomplete. Make sure your neurologist's office includes specific seizure counts, medication names with dates tried, and reasons for discontinuation.

Step-by-Step: Fastest Path to Approval

  1. Contact BCBS Member Services (number on your insurance card) to request the current prior authorization form
  2. Schedule appointments with your neurologist to document current seizure control and review prior therapies
  3. Complete REMS enrollment at finteplarems.com and schedule baseline echo
  4. Gather medical records showing failed trials of formulary alternatives like clobazam, valproate, or levetiracetam
  5. Submit complete PA packet via fax or provider portal (verify current submission method with BCBS)
  6. Follow up in 5-7 business days if you haven't received a determination
  7. If approved, enroll in copay assistance before first fill to minimize out-of-pocket costs

Cost Reduction Strategies

Even with insurance coverage, Fintepla can be expensive. Here's how to minimize your family's costs:

UCB ONWARD Copay Assistance

The manufacturer offers significant cost support for commercially insured patients:

  • Eligible patients pay $0-25 per prescription
  • Available for commercial insurance only (not Medicaid/Medicare)
  • No income restrictions or complicated applications
  • Enroll at 1-833-GO-DS-LGS (1-833-463-7547)

Counterforce Health helps families navigate these manufacturer programs alongside insurance appeals, ensuring you're maximizing both coverage and cost assistance opportunities.

Foundation Support Options

While most epilepsy foundations don't cover medication costs directly, they can help with related expenses:

Foundation Grant Amount What's Covered Application Period
Dravet Syndrome Foundation Up to $1,500/year Medical equipment, therapy tools Rolling (deadline Dec 1)
LGS Foundation Up to $1,500/5 years DME, genetic testing, seizure devices Opens February annually

Pharmacy Choice Matters

  • Specialty pharmacies often provide better support navigating insurance issues than retail chains
  • Mail-order options through your BCBS plan may offer 90-day supplies with lower copays
  • Hospital-affiliated pharmacies can sometimes bill as medical benefits rather than pharmacy benefits

When Coverage Gets Denied

Don't panic if your initial prior authorization is denied. About 35% of specialty drug requests face initial denials, but many succeed on appeal with better documentation.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Not medically necessary" Submit detailed seizure logs showing inadequate control on current therapy
"Step therapy not completed" Document failed trials with specific dates, dosages, and reasons for discontinuation
"Missing REMS documentation" Provide REMS enrollment confirmation and baseline echo results
"Diagnosis not supported" Include genetic testing results (Dravet) or comprehensive EEG reports (LGS)
"Age restriction" Verify patient is 2+ years with birth certificate if needed

Internal Appeals Process

BCBS typically offers two levels of internal appeals:

  1. First-level review (14-30 days) - often handled by pharmacy staff
  2. Second-level review (14-30 days) - involves medical director or external physician

For each appeal, include:

  • Updated clinical information showing continued medical necessity
  • Peer-reviewed literature supporting Fintepla's effectiveness in your child's condition
  • Letter from treating neurologist explaining why formulary alternatives are inadequate

New Jersey's External Appeal Rights

If BCBS upholds their denial after internal appeals, New Jersey offers one of the country's strongest external review processes.

IHCAP External Appeal Process

New Jersey contracts with Maximus Federal Services to provide independent medical reviews. Here's what you need to know:

  • Filing deadline: 4 months (120 days) after final internal denial
  • Review timeline: 45 days for standard cases, 48 hours for urgent situations
  • Cost to you: $0 - insurers pay all review fees
  • Success rate: Approximately 50% of external appeals favor consumers nationally

How to File with Maximus

  1. Complete the external appeal application (available at njihcap.maximus.com)
  2. Gather required documents:
    • Copy of BCBS denial letters
    • Medical records supporting Fintepla's necessity
    • General medical records release form
  3. Submit via online portal, fax, or mail to Maximus
  4. Request expedited review if delays could seriously harm your child's health
Note: The external reviewers are independent physicians with epilepsy expertise who evaluate whether BCBS's denial was consistent with standard medical practice.

Clinician Corner

Medical Necessity Letter Checklist

When writing letters supporting Fintepla coverage, include:

Clinical History:

  • Specific seizure types and frequency before/after current therapies
  • Functional impact on development, cognition, and quality of life
  • Emergency department visits or hospitalizations due to seizures

Prior Therapy Documentation:

  • Medication names, dosages, duration of trials
  • Specific reasons for discontinuation (lack of efficacy vs. adverse effects)
  • Contraindications to formulary alternatives

Evidence Base:

  • Reference FDA approval for patient's specific syndrome
  • Cite clinical trial data showing Fintepla's efficacy in Dravet/LGS
  • Include relevant treatment guidelines from epilepsy societies

Safety Monitoring:

  • Confirm REMS enrollment and cardiac monitoring plan
  • Address any drug interaction concerns
  • Outline follow-up schedule for efficacy and safety assessment

The platform Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing payer policies and crafting evidence-backed rebuttals that speak directly to each plan's coverage criteria.

Frequently Asked Questions

How long does BCBS prior authorization take in New Jersey? Standard prior authorizations are processed within 14 days. Urgent requests (where delays could cause serious harm) must be reviewed within 24-48 hours.

What if Fintepla isn't on my plan's formulary? You can request a formulary exception by demonstrating that all covered alternatives are ineffective or cause unacceptable side effects. Include documentation of failed trials with formulary drugs.

Can I get coverage if my child hasn't tried every anti-seizure medication? Yes, if there are medical reasons to avoid certain medications (allergies, contraindications, or high likelihood of failure based on seizure type), step therapy requirements can be waived.

Does the copay card work with all BCBS plans? The ONWARD copay assistance works with most commercial BCBS plans but not with government programs (Medicaid, Medicare, CHIP). Verify eligibility when enrolling.

What happens if BCBS changes their formulary mid-year? Plans generally can't remove drugs mid-year without 60 days' notice. If Fintepla is moved to a higher tier or removed, you can request a formulary exception to maintain current coverage.

How do I request an expedited appeal? Contact BCBS member services and explain that delays in coverage could cause serious harm to your child's health. Provide supporting documentation from your neurologist.

Can I continue current Fintepla during an appeal? If you're already on Fintepla and coverage is being terminated, you may be able to continue treatment during the appeal process. This varies by plan type and situation.

What if I move to another state while on Fintepla? Coverage policies vary significantly between Blue Cross Blue Shield plans in different states. Contact your new plan immediately to understand their requirements and begin any necessary prior authorization processes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult with your healthcare providers about treatment decisions. For personalized assistance with insurance appeals and coverage strategies, consider working with specialists like Counterforce Health who focus on turning denials into approvals through evidence-based advocacy.

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