By Counterforce Health Team in Fintepla (fenfluramine) —

Get Fintepla (fenfluramine) Covered by Cigna in Washington: Complete Prior Authorization Guide with Appeals

Answer Box: Getting Fintepla Covered by Cigna in Washington

Fintepla (fenfluramine) requires prior authorization from Cigna for Dravet syndrome or Lennox-Gastaut syndrome patients. Key requirements: confirmed diagnosis with ICD-10 codes G40.833/G40.834 (Dravet) or G40.81 (LGS), documented failure of standard anti-seizure medications, REMS enrollment, and baseline echocardiogram. If denied, Washington residents have strong appeal rights including external independent review through certified IROs. First step: Gather seizure logs, prior medication history, and request REMS enrollment from your neurologist today.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. ICD-10 Coding and Documentation
  4. REMS Enrollment and Echocardiography
  5. Common Denial Reasons & Solutions
  6. Washington Appeals Process
  7. Cost Support Options
  8. When to Contact Regulators
  9. FAQ

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Diagnosis Dravet syndrome or Lennox-Gastaut syndrome ICD-10: G40.833/G40.834 or G40.81 Cigna PA Policy
Age ≥2 years old Birth certificate or medical record FDA Label
Prior Therapy Failed ≥2 standard ASMs Medication history with dates/outcomes Cigna PA Policy
REMS Enrollment Prescriber and patient certified REMS enrollment confirmation FDA REMS
Cardiac Monitoring Baseline echocardiogram Echo report showing normal valves/PASP ≤35 FDA Label
Prescriber Neurologist or epileptologist Medical license verification Cigna PA Policy
Benefit Type Specialty pharmacy NDC billing (not J-code) Multiple Payer Policies

Step-by-Step: Fastest Path to Approval

1. Confirm Diagnosis and Coding

Who: Neurologist
Timeline: Same day
Your neurologist must document the specific epilepsy syndrome with proper ICD-10 codes:

  • Dravet syndrome: G40.833 (with status epilepticus) or G40.834 (without status epilepticus)
  • Lennox-Gastaut syndrome: G40.81

2. Document Prior Treatment Failures

Who: Patient/caregiver with clinic staff
Timeline: 1-2 days
Compile a complete list of previously tried anti-seizure medications including:

  • Valproate, clobazam, stiripentol (common for Dravet)
  • Lamotrigine, rufinamide, topiramate (common for LGS)
  • Doses, duration, and specific reasons for discontinuation

3. REMS Enrollment

Who: Prescriber initiates, patient completes
Timeline: 3-5 business days

  • Prescriber enrolls at FINTEPLA REMS portal
  • Patient completes enrollment form
  • Order baseline echocardiogram

4. Baseline Echocardiogram

Who: Cardiologist or echo lab
Timeline: 1-2 weeks
Echo must show:

  • No moderate or severe valvular regurgitation
  • Pulmonary artery systolic pressure (PASP) ≤35 mm Hg
  • No evidence of pulmonary arterial hypertension

5. Submit Prior Authorization

Who: Prescriber or clinic staff
Timeline: 1-2 business days
Submit via Cigna provider portal or fax with:

  • Completed PA form
  • Letter of medical necessity
  • Echo report and REMS documentation
  • Prior medication history

6. Follow Up on Decision

Who: Patient or clinic
Timeline: 15-30 days (standard), 72 hours (expedited)
Cigna typically responds within 15 business days for standard requests.

7. Appeal if Denied

Who: Patient with provider support
Timeline: Must start within 180 days of denial
Use Washington's strong appeal rights including external independent review.

ICD-10 Coding and Documentation

Dravet Syndrome Coding

Primary codes:

  • G40.833: Dravet syndrome, intractable, with status epilepticus
  • G40.834: Dravet syndrome, intractable, without status epilepticus

Key documentation elements:

  • Onset in infancy with pharmacoresistant epilepsy
  • Multiple seizure types (myoclonic, generalized tonic-clonic, focal)
  • Developmental delays or cognitive impairment
  • SCN1A genetic testing results (if available)
Clinician Tip: The "not intractable" status does not apply to Dravet syndrome per ICD-10 guidelines. Always use G40.833 or G40.834.

Lennox-Gastaut Syndrome Coding

Primary code: G40.81 - Lennox-Gastaut syndrome

Documentation requirements:

  • Multiple seizure types (tonic, atonic, atypical absence, myoclonic)
  • Onset typically before age 4
  • Intellectual disability or developmental delay
  • EEG evidence when available (slow spike-and-wave patterns)

REMS Enrollment and Echocardiography Requirements

Fintepla can only be dispensed through the FDA-mandated FINTEPLA REMS program due to risks of valvular heart disease and pulmonary arterial hypertension.

Prescriber Requirements

  • Complete REMS certification training
  • Enroll each patient in the REMS database
  • Order baseline and periodic echocardiograms
  • Submit Patient Status Forms documenting cardiac safety

Patient Requirements

  • Complete REMS enrollment form
  • Undergo echocardiograms at baseline, every 6 months during treatment, and 3-6 months after discontinuation
  • Obtain medication only from REMS-certified pharmacies

Echocardiogram Specifications

The echo must evaluate for:

  • Valvular heart disease: Mild or greater aortic regurgitation, moderate or greater mitral regurgitation
  • Pulmonary arterial hypertension: PASP >35 mm Hg indicates increased risk

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing REMS enrollment Complete patient and prescriber enrollment REMS confirmation emails/forms
No baseline echo Order and complete echocardiogram Full cardiology report with valve assessment
Insufficient prior therapy Document ≥2 failed ASMs with specific details Medication history with doses, dates, outcomes
Non-formulary status Request formulary exception Medical necessity letter citing FDA approval
Step therapy not met Document contraindications or failures of preferred drugs Clinical notes explaining why alternatives inappropriate

Washington Appeals Process

Washington provides robust protections for insurance denials under RCW 48.43.535.

Internal Appeal (Required First Step)

Timeline: Must file within 180 days of denial
Process: Submit written appeal to Cigna with supporting documentation
Decision timeline: 30 days (standard), 72 hours (expedited)

External Independent Review

When available: After final internal denial
Timeline: Request within 4 months of final denial
Process: Independent Review Organization (IRO) reviews case
Decision timeline: 45 days (standard), 72 hours (expedited)
Binding: IRO decision is binding on Cigna

Washington Advantage: The state's external review process is particularly strong for rare disease medications, with access to specialist reviewers at major medical centers.

Sample Appeal Language

For internal appeals to Cigna:

"I request a full internal appeal of the denial for Fintepla (fenfluramine) under RCW 48.43.535. This medication is FDA-approved for [Dravet syndrome/LGS] and is medically necessary because [patient] has failed [list specific medications] and continues to experience [frequency] seizures despite optimal therapy. All REMS requirements have been met including baseline echocardiogram showing [normal findings]. If this appeal is denied, please provide information about my right to external independent review under Washington state law."

Cost Support Options

Manufacturer Programs

  • UCB Patient Assistance Program: Income-based free drug program
  • Commercial copay support: Up to $15,000 annually for eligible patients
  • Contact: 1-844-599-CARE (2273)

Foundation Support

  • Patient Access Network (PAN) Foundation: Epilepsy fund for underinsured patients
  • HealthWell Foundation: Rare disease assistance programs
  • National Organization for Rare Disorders (NORD): Patient assistance programs

Washington State Resources

  • Apple Health (Medicaid): Covers Fintepla with prior authorization
  • Washington State Prescription Drug Program: Additional assistance for qualifying residents

When to Contact Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Cigna fails to respond to appeals within required timelines
  • You need help understanding your appeal rights
  • You believe Cigna is not following Washington insurance laws

Consumer Advocacy Line: 1-800-562-6900

FAQ

Q: How long does Cigna prior authorization take in Washington?
A: Standard PA decisions take up to 15 business days. Expedited reviews (for urgent medical situations) must be completed within 72 hours.

Q: What if Fintepla is non-formulary on my Cigna plan?
A: You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. Include a detailed letter from your neurologist.

Q: Can I request an expedited appeal?
A: Yes, if waiting for a standard review would seriously jeopardize your health. Your doctor must provide documentation supporting the urgent need.

Q: Does step therapy apply if I tried medications outside Washington?
A: Yes, prior therapy trials from any location count toward step therapy requirements. Ensure you have documentation of the medications tried and outcomes.

Q: How much does Fintepla cost without insurance?
A: The typical cash price is approximately $1,595 for a 30-mL bottle, with total monthly costs varying by prescribed dose.

Q: What happens if the external review upholds Cigna's denial?
A: The IRO decision is final for the insurance appeal process, but you may still access manufacturer assistance programs or explore other coverage options.

From Our Advocates

We've seen many Washington families successfully overturn initial Fintepla denials by ensuring complete REMS documentation and providing detailed seizure logs showing the impact on daily life. The key is demonstrating both medical necessity and safety compliance—Washington's external review process is particularly effective when all clinical criteria are clearly documented.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and crafting evidence-backed responses aligned to each plan's own criteria. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements for medications like Fintepla, ensuring that clinical evidence meets payer expectations while tracking deadlines and procedural requirements.

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 plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage questions. For personalized assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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