By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (Fenfluramine) Covered by Aetna CVS Health in Washington: Complete Prior Authorization Guide

Quick Answer: Getting Fintepla Covered by Aetna CVS Health in Washington

Fintepla (fenfluramine) requires prior authorization from Aetna CVS Health for patients with Dravet syndrome or Lennox-Gastaut syndrome (ages 2+). The fastest path to approval: (1) Ensure REMS enrollment and baseline echocardiogram are complete, (2) Submit Aetna's PA form with diagnosis documentation (ICD-10 codes G40.83 for Dravet, G40.82 for LGS) and evidence of failed preferred antiseizure medications, (3) Include supporting clinical notes and specialist letters. If denied, Washington residents have strong appeal rights through the state's external review process via independent review organizations (IROs). Start today by downloading Aetna's PA form and contacting your prescriber.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You Need More Information
  7. If Your Request Is Denied
  8. Washington State External Review Process
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This comprehensive guide helps patients with Dravet syndrome or Lennox-Gastaut syndrome—and their healthcare providers—navigate Aetna CVS Health's prior authorization process for Fintepla (fenfluramine) in Washington state.

Fintepla is an FDA-approved serotonergic antiseizure medication that requires enrollment in a Risk Evaluation and Mitigation Strategy (REMS) program due to potential cardiac risks. With proper documentation and persistence, many patients successfully obtain coverage, even after initial denials.

Who this helps: Patients with confirmed Dravet syndrome or LGS, their families, neurologists, epileptologists, and clinic staff managing prior authorizations.

Before You Start: Verify Your Coverage

Check Your Plan Type and Formulary Status

  1. Confirm your Aetna plan type by reviewing your insurance card or member portal
  2. Verify Fintepla's formulary tier using Aetna's current drug guide for your specific plan
  3. Check if you have pharmacy or medical benefits coverage for specialty medications
Note: Fintepla is typically covered under pharmacy benefits and requires prior authorization across all Aetna CVS Health plans.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all indications Aetna PA Drug List
Covered Indications Dravet syndrome, LGS (age ≥2) Aetna Clinical Policy
Step Therapy Often required Aetna Formulary Guidelines
REMS Enrollment Mandatory FDA REMS Program
Approval Duration Up to 12 months Aetna Clinical Policy

Gather Required Documentation

Essential Clinical Documentation

For Dravet Syndrome (ICD-10: G40.83):

  • Seizure onset in first year of life with normal initial development
  • Documentation of multiple seizure types (focal clonic, generalized, myoclonic)
  • SCN1A genetic testing results (when available)
  • EEG and MRI reports

For Lennox-Gastaut Syndrome (ICD-10: G40.82):

  • Seizure onset before age 8 with multiple seizure types
  • EEG showing slow spike-and-wave discharges (<2.5 Hz)
  • Evidence of cognitive/behavioral impairment
  • Documentation of tonic seizures for strict LGS diagnosis

REMS Program Requirements

Before submitting your PA request, ensure:

  • Prescriber REMS enrollment is complete
  • Patient REMS enrollment via Patient Enrollment Form
  • Baseline echocardiogram has been performed and documented
  • Ongoing monitoring plan for 6-month echocardiograms is established
Tip: UCB offers support programs that may provide echocardiograms at reduced cost for eligible patients. Contact Fintepla patient support for details.

Step Therapy Documentation

Aetna typically requires documentation of failed trials with preferred antiseizure medications. Document:

  • Names of ASMs tried (e.g., clobazam, valproate, levetiracetam)
  • Dosages and duration of each trial
  • Specific outcomes (lack of efficacy, intolerable side effects, contraindications)
  • Clinical rationale for why Fintepla is medically necessary

Submit Your Prior Authorization Request

Step-by-Step Submission Process

  1. Download the PA form: Use Aetna's Global Prior Authorization Form
  2. Complete all required sections:
    • Patient demographics and insurance information
    • Prescriber information and NPI
    • Drug details (Fintepla, NDC, dosing)
    • Diagnosis with ICD-10 codes
    • Clinical justification
  3. Attach supporting documents:
    • REMS enrollment confirmation
    • Baseline echocardiogram report
    • Prior therapy failure documentation
    • Specialist consultation notes
  4. Submit via preferred method:
    • Fax: Check your specific plan's PA fax number
    • Portal: Aetna provider portal (for healthcare providers)
    • Mail: Include with PA form (verify current address)

Medical Necessity Letter Checklist

Your prescriber should include a comprehensive medical necessity letter addressing:

  • Problem statement: Specific seizure types and frequency
  • Prior treatments: Detailed history of failed ASMs with outcomes
  • Clinical rationale: Why Fintepla is appropriate for this patient
  • Guideline support: Reference to FDA labeling and epilepsy treatment guidelines
  • Monitoring plan: REMS compliance and ongoing cardiac monitoring

Follow-Up and Timelines

Expected Processing Times

  • Standard PA decisions: 30-45 days for commercial plans
  • Urgent/expedited requests: 72 hours when medically necessary
  • Medicare Part D: 72 hours standard, 24 hours expedited

Follow-Up Best Practices

  • Call after 5 business days to confirm receipt
  • Document reference numbers and representative names
  • Request status updates weekly if approaching deadline
  • Escalate to supervisor if experiencing delays beyond stated timeframes
Sample Call Script: "I'm calling to check the status of a prior authorization request for Fintepla submitted on [date]. The reference number is [number]. Can you provide an update on the review timeline?"

If You Need More Information

Aetna may request additional clinical information during review. Common requests include:

  • Updated clinical notes showing current seizure frequency
  • Additional specialist consultation from epileptologist
  • Clarification of REMS compliance and monitoring plan
  • Documentation of contraindications to preferred alternatives

Response timeline: You typically have 14 days to provide additional information. Submit promptly to avoid automatic denial.

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Insufficient step therapy Provide detailed documentation of failed preferred ASMs
Missing REMS documentation Submit REMS enrollment confirmation and baseline echo
Diagnosis not supported Include genetic testing, EEG reports, specialist consultation
Not medically necessary Request peer-to-peer review with prescribing specialist

First-Level Appeal Process

  1. File within 180 days of denial notice
  2. Submit appeal form with additional clinical evidence
  3. Request peer-to-peer review between prescriber and Aetna medical director
  4. Include patient impact statement describing seizure burden and quality of life

Washington State External Review Process

Washington residents have robust appeal rights through the state's external review system.

Timeline and Process

  • File external review within 60 days of final internal denial
  • Submit request to Washington Office of Insurance Commissioner (OIC)
  • Provide additional evidence within 5 business days of IRO assignment
  • Receive decision within 20 calendar days (standard) or 72 hours (expedited)

Contact Information

Washington Office of Insurance Commissioner

Important: The IRO decision is binding on Aetna and free to patients. Washington pays IRO fees.

From our advocates: "We've seen several Washington patients successfully overturn Fintepla denials through the external review process. The key is submitting comprehensive clinical documentation that clearly demonstrates medical necessity and compliance with REMS requirements. One patient's external review was approved within 15 days after the IRO panel included an epilepsy specialist who understood the unique challenges of treating Dravet syndrome."

Renewal and Re-Authorization

Fintepla authorizations typically require renewal every 12 months. Plan ahead by:

  • Starting renewal 60 days early to avoid coverage gaps
  • Updating clinical documentation with current seizure logs and response to treatment
  • Including recent echocardiogram results showing continued cardiac safety
  • Documenting ongoing medical necessity and treatment goals

Quick Reference Checklist

Before Submitting:

  • Confirm Dravet syndrome or LGS diagnosis with ICD-10 codes
  • Complete REMS enrollment for prescriber and patient
  • Obtain baseline echocardiogram
  • Document failed preferred ASM trials
  • Download current Aetna PA form

During Review:

  • Follow up within 5 business days
  • Document all interactions and reference numbers
  • Respond promptly to requests for additional information
  • Escalate delays beyond stated timelines

If Denied:

  • File internal appeal within 180 days
  • Request peer-to-peer review
  • Consider external review through Washington OIC
  • Gather additional clinical evidence

For patients and healthcare providers navigating complex prior authorization processes, Counterforce Health specializes in turning insurance denials into successful appeals by identifying specific denial reasons and crafting evidence-backed rebuttals aligned with each plan's requirements.

FAQ

How long does Aetna CVS Health prior authorization take for Fintepla in Washington? Standard PA decisions typically take 30-45 days for commercial plans. Urgent requests can be processed within 72 hours when medical necessity is demonstrated.

What if Fintepla is not on my Aetna formulary? You can request a formulary exception by providing clinical documentation showing medical necessity and failure of formulary alternatives. The process follows the same PA procedures.

Can I request an expedited appeal if my child's seizures are worsening? Yes, Washington allows expedited appeals when delay would jeopardize health. Contact Aetna immediately and request urgent processing, then follow up with the Washington OIC if needed.

Does step therapy apply if my child failed ASMs in another state? Medical records from other states are valid for step therapy documentation. Ensure all prior therapies are clearly documented with specific outcomes and timeframes.

What happens if my employer plan is self-funded? Self-funded ERISA plans may not be subject to Washington state external review, but many voluntarily provide similar processes. Check with your HR department and consider contacting the U.S. Department of Labor if needed.

How much does Fintepla cost without insurance? Typical retail cost for a 30-mL bottle is around $1,595, though monthly costs vary by prescribed dose. UCB offers patient assistance programs that may help reduce costs.

Can I get help with the appeal process? Yes, the Washington OIC provides free consumer assistance at 1-800-562-6900. Additionally, Counterforce Health offers specialized appeal services for complex medication denials.

What documentation do I need for REMS compliance? You need prescriber REMS enrollment confirmation, patient enrollment forms, baseline echocardiogram results, and a monitoring plan for ongoing 6-month cardiac assessments.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance company directly for plan-specific requirements. Coverage policies and procedures may change; verify current requirements with official sources.

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