By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (Fenfluramine) Covered by Aetna (CVS Health) in New York: Complete Guide to Prior Authorization and Appeals

Answer Box: Fastest Path to Fintepla Coverage

Is Fintepla covered by Aetna (CVS Health) in New York? Yes, but requires prior authorization for seizures associated with Dravet syndrome or Lennox-Gastaut syndrome in patients ≥2 years old. Fastest approval path: (1) Enroll in the FINTEPLA REMS program with baseline echocardiogram, (2) Submit Aetna's prior authorization form documenting diagnosis and failed prior therapies, (3) Use ONWARD copay assistance to reduce costs to $0-$25/month. Start today: Call your neurologist to confirm REMS enrollment and request PA submission.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Clinical Criteria
  5. Cost and Copay Assistance
  6. Denials and Appeals
  7. Renewals and Ongoing Coverage
  8. CVS Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues

Coverage Basics

Is Fintepla Covered by Aetna (CVS Health)?

Yes, Aetna covers Fintepla as a specialty medication with prior authorization. Coverage is limited to FDA-approved indications:

  • Dravet syndrome-associated seizures in patients ≥2 years
  • Lennox-Gastaut syndrome-associated seizures in patients ≥2 years

Which Aetna Plans Cover Fintepla?

Most Aetna commercial plans, Medicare Advantage, and Medicaid managed care plans include Fintepla on their specialty formulary. However, specific coverage varies by plan type and employer group.

Tip: Call the member services number on your Aetna ID card to confirm your specific plan's coverage and formulary tier.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

1. REMS Enrollment (Required First)

2. Baseline Echocardiogram

  • Who: Patient (ordered by neurologist)
  • What: Transthoracic echo to screen for valvular heart disease
  • Timeline: Schedule within 1-2 weeks of REMS enrollment

3. Submit Prior Authorization

  • Who: Neurologist's office
  • What: Aetna Fintepla PA form
  • How: Fax to CVS Caremark or submit via provider portal
  • Timeline: 5-15 business days for standard decision

4. CVS Specialty Pharmacy Transfer

  • Who: Automatic after PA approval
  • What: Prescription transferred to REMS-certified specialty pharmacy
  • Timeline: 1-2 business days after approval

Timing and Deadlines

Standard Prior Authorization Timeline

Step Timeline Notes
REMS enrollment 1-3 business days Must complete before PA
Baseline echo 1-2 weeks Required for REMS
PA decision 5-15 business days Standard Aetna timeline
Expedited PA 72 hours For urgent medical needs
First fill 2-3 business days After PA approval

When to Request Expedited Review

Request expedited prior authorization if:

  • Patient has frequent seizures (≥4 per month)
  • Recent status epilepticus
  • Hospitalization due to seizures
  • Risk of serious injury from seizures

Clinical Criteria

Required Documentation for Approval

Based on Aetna's 2024 policy, your neurologist must document:

Diagnosis Requirements:

  • Confirmed Dravet syndrome or Lennox-Gastaut syndrome
  • ICD-10 codes (G40.83 for Dravet, G40.82 for LGS)
  • Supporting evidence (genetic testing, EEG, clinical history)

Step Therapy Requirements:

  • Trial and inadequate response to ≥2 other antiseizure medications
  • Common required trials: valproate, clobazam, levetiracetam, topiramate
  • Documentation of failure, intolerance, or contraindication

Safety Requirements:

  • REMS enrollment confirmation
  • Baseline echocardiogram results
  • Plan for ongoing cardiac monitoring every 6 months
Clinician Corner: Medical necessity letters should include baseline seizure frequency, specific medications tried with doses and duration, reasons for discontinuation, and quantified treatment goals (e.g., "reduce convulsive seizures by ≥50%").

Cost and Copay Assistance

Expected Costs with Aetna Coverage

Without Copay Assistance:

  • Specialty tier coinsurance: typically 25-40% of list price
  • Monthly out-of-pocket: $1,000-$2,000+ until deductible/max out-of-pocket met

With ONWARD Copay Assistance:

How to Enroll in Cost Assistance

  1. Contact ONWARD Support: Call 1-833-463-7547
  2. Eligibility: Commercial insurance, U.S. resident, valid prescription
  3. Enrollment: Complete application before first fill
  4. Timeline: Active within 24-48 hours

For Aetna Medicaid patients, typical out-of-pocket costs are $4.95-$9.85 per month based on state copay rules.

Denials and Appeals

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Medical necessity letter Seizure logs, hospitalization records, functional impact
"Step therapy not met" Document prior failures Medication list with doses, durations, outcomes
"Experimental/investigational" FDA approval evidence FDA label, clinical guidelines
"REMS not enrolled" Confirm enrollment REMS confirmation number, echo report

Aetna Internal Appeals Process

Timeline: 180 days from denial notice to file appeal

How to File:

  1. Call Aetna member services or submit written appeal form
  2. Include denial letter, clinical records, and medical necessity letter
  3. Request expedited review if clinically urgent

Decision Timeline:

  • Standard appeals: 30-45 days
  • Expedited appeals: 72 hours

New York External Appeal Rights

If Aetna denies your internal appeal, New York residents can request an independent external review through DFS.

Key Benefits:

  • Independent medical experts review your case
  • Binding decision on Aetna
  • 4-month deadline from internal appeal decision
  • 72-hour expedited review for urgent cases
  • $25 maximum fee (waived for financial hardship)

Success Factors:

  • Strong medical necessity letter from neurologist
  • Comprehensive treatment history
  • Evidence of FDA approval for your condition
  • Documentation of seizure burden and functional impact

At Counterforce Health, we've seen that external appeals in New York have meaningful overturn rates when supported by robust clinical evidence and clear documentation of failed prior therapies.

Renewals and Ongoing Coverage

When Reauthorization is Required

Aetna typically grants 12-month authorizations for Fintepla, requiring renewal annually.

Renewal Requirements:

  • Continued diagnosis of Dravet syndrome or LGS
  • Clinical benefit documentation (seizure frequency reduction)
  • Up-to-date echocardiogram (within 6 months)
  • No serious cardiac adverse events

Timeline: Submit renewal 30-60 days before current authorization expires.

CVS Specialty Pharmacy Requirements

Why Fintepla Must Use Specialty Pharmacy

Fintepla requires REMS-certified specialty pharmacy dispensing. CVS Specialty is Aetna's preferred partner for most specialty medications.

Dispensing Process:

  1. Prescription automatically transferred after PA approval
  2. CVS Specialty contacts patient for clinical review
  3. Schedule home delivery (standard in New York)
  4. Receive medication with temperature monitoring

Refill Process:

  • No automatic refills for specialty medications
  • CVS Specialty contacts you when refill window opens
  • Brief clinical questionnaire required each refill
  • REMS reauthorization confirmed before each dispensing

Troubleshooting Common Issues

Frequently Asked Questions

Q: How long does Aetna prior authorization take in New York? A: Standard decisions: 5-15 business days. Expedited decisions: 72 hours for urgent medical needs.

Q: What if Fintepla is non-formulary on my Aetna plan? A: Request a formulary exception with medical necessity documentation. Your neurologist can submit this with the initial PA.

Q: Can I request an expedited appeal? A: Yes, if delay would seriously jeopardize your health. Include documentation of seizure frequency and hospitalization risk.

Q: Does step therapy apply if I've tried medications outside New York? A: Yes, document all prior therapies regardless of location. Include medical records from previous neurologists.

When to Escalate

Contact these resources if standard appeals are unsuccessful:

  • New York DFS External Appeal: File online or call 1-800-342-3736
  • Community Health Advocates: Free insurance counseling at 888-614-5400
  • Epilepsy Foundation: Local chapter support and advocacy resources

Key Takeaways

Getting Fintepla covered by Aetna (CVS Health) in New York requires careful coordination of REMS requirements, clinical documentation, and prior authorization submission. The process typically takes 2-4 weeks when all requirements are met upfront.

Critical success factors:

  1. Complete REMS enrollment before PA submission
  2. Document clear diagnosis and failed prior therapies
  3. Submit comprehensive clinical records
  4. Use manufacturer copay assistance for commercial plans
  5. Know your appeal rights under New York law

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals with the right clinical evidence and procedural requirements. Learn more about our appeals support services.

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Consult your healthcare provider and insurance plan for personalized guidance.

Sources & Further Reading

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