By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (fenfluramine) Covered by Blue Cross Blue Shield in Georgia: Complete Prior Authorization Guide

Answer Box: Getting Fintepla Covered in Georgia

To get Fintepla (fenfluramine) covered by Blue Cross Blue Shield in Georgia, you'll need prior authorization showing: (1) confirmed Dravet syndrome or Lennox-Gastaut syndrome diagnosis, (2) documented failure of 2-3 generic anti-seizure medications, and (3) enrollment in the REMS program with baseline echocardiogram. Start today by calling the member services number on your insurance card to request the specific Fintepla PA form for your plan. Most approvals take 5-15 business days with complete documentation.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Plan Details
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You're Asked for More Information
  7. If Your Request Is Denied
  8. Appeals Process in Georgia
  9. Renewal and Re-Authorization
  10. Common Denial Reasons & Solutions
  11. FAQ
  12. Quick Reference Checklist

What This Guide Covers

This guide helps patients, families, and clinicians navigate Blue Cross Blue Shield (BCBS) prior authorization for Fintepla (fenfluramine) in Georgia. Fintepla is a specialty anti-seizure medication used to treat seizures associated with Dravet syndrome and Lennox-Gastaut syndrome (LGS).

Who this helps:

  • Patients diagnosed with Dravet syndrome or LGS
  • Parents and caregivers managing pediatric epilepsy
  • Neurologists and epileptologists submitting PA requests
  • Specialty pharmacies coordinating coverage

In Georgia, most BCBS members are covered through Anthem Blue Cross Blue Shield, which requires prior authorization for Fintepla due to its high cost and safety monitoring requirements.

Before You Start: Verify Your Plan Details

Step 1: Identify Your Specific BCBS Plan

Georgia has several BCBS options:

  • Anthem Blue Cross Blue Shield (most common commercial plans)
  • State Health Benefit Plan (SHBP) with Anthem and CVS Caremark
  • Medicaid managed care through various Blues plans

Call the member services number on your insurance card and ask:

  • "Is Fintepla on my formulary?"
  • "What tier is it on, and is prior authorization required?"
  • "Which specialty pharmacy must I use?"

Step 2: Confirm Specialty Pharmacy Requirements

Fintepla is typically classified as a specialty medication requiring dispensing through in-network specialty pharmacies. For most Anthem BCBS Georgia plans, this includes:

  • CVS Specialty (most common)
  • BioPlus Specialty Pharmacy
  • CenterWell Pharmacy
Note: Fintepla is also subject to REMS (Risk Evaluation and Mitigation Strategy) requirements, so only REMS-certified specialty pharmacies can dispense it.

Gather What You Need

Clinical Documentation Required

Diagnosis Requirements:

  • Confirmed Dravet syndrome (ICD-10: G40.833 or G40.834) OR
  • Confirmed Lennox-Gastaut syndrome (use appropriate epilepsy code + explicit LGS documentation)
  • Patient age ≥2 years at treatment initiation

Prior Therapy Documentation: Most BCBS plans require documented failure, intolerance, or contraindication to at least 2-3 generic anti-seizure medications before approving Fintepla. Common step therapy requirements include trials of:

  • Levetiracetam
  • Valproic acid
  • Topiramate
  • Clobazam
  • Lamotrigine

For each prior medication, document:

  • Drug name, dose, duration of trial
  • Reason for discontinuation (ineffective, adverse effects, contraindications)
  • Specific dates of treatment

REMS Program Requirements

Before PA submission, ensure:

  1. Prescriber is REMS-certified through the Fintepla REMS program
  2. Patient is enrolled in the REMS program
  3. Baseline echocardiogram completed and submitted to REMS
  4. Patient Status Form completed documenting cardiac clearance

Required Forms and Documents

  • BCBS-specific Fintepla prior authorization form
  • Letter of medical necessity from prescriber
  • Recent clinic notes documenting seizure history
  • Baseline echocardiogram report
  • Proof of REMS enrollment
  • Medication history printout

Submit the Prior Authorization Request

Electronic Submission (Preferred)

  1. Log into the Anthem provider portal (typically through Availity)
  2. Navigate to Pharmacy → Prior Authorization
  3. Search for "Fintepla" or "fenfluramine"
  4. Complete the electronic PA form
  5. Upload all supporting documents
  6. Save the confirmation number

Fax Submission (Alternative)

If electronic submission isn't available:

  • Use the fax number provided on your plan-specific PA form
  • Include a cover sheet with patient information
  • Send all documents in a single transmission
  • Follow up to confirm receipt

Clean Request Packet Checklist

✓ Completed PA form with all fields filled ✓ Prescriber signature and NPI number ✓ Patient demographics and insurance information ✓ Diagnosis with appropriate ICD-10 code ✓ Step therapy documentation (prior medication trials) ✓ REMS enrollment confirmation ✓ Baseline echocardiogram report ✓ Letter of medical necessity

Follow-Up and Timelines

Georgia State Requirements

Under Georgia insurance law, BCBS must respond to prior authorization requests within:

  • Standard requests: 15 calendar days
  • Expedited requests: 72 hours (for urgent medical situations)

Follow-Up Schedule

Day 3: Call to confirm receipt of your PA request Day 10: Check status if no response received Day 14: If approaching deadline, call to request expedited review

Sample Call Script

"Hi, I'm calling to check the status of a prior authorization request for Fintepla for [patient name], member ID [number], submitted on [date]. The confirmation number is [number]. Can you tell me the current status and expected decision date?"

If You're Asked for More Information

Common requests for additional information include:

Medical Necessity Questions:

  • More detailed seizure frequency documentation
  • Specific reasons why alternative medications failed
  • Current seizure impact on daily functioning

REMS Documentation:

  • Updated Patient Status Form
  • Confirmation of prescriber REMS certification
  • Detailed echocardiogram interpretation

Response Strategy:

  • Respond within the timeframe specified (usually 5-10 business days)
  • Address each specific question directly
  • Include supporting literature when appropriate

If Your Request Is Denied

Understanding Denial Codes

Common denial reasons for Fintepla:

  • Step therapy requirements not met
  • Missing REMS enrollment documentation
  • Insufficient diagnosis documentation
  • Age requirements not met
  • Drug-drug interaction concerns

First-Level Appeal Options

  1. Peer-to-Peer Review: Request a call between your prescriber and the BCBS medical director
  2. Written Appeal: Submit additional clinical documentation
  3. Expedited Appeal: For urgent situations requiring immediate treatment
From our advocates: "We've seen many Fintepla denials overturned by providing more detailed seizure diary documentation and emphasizing the safety monitoring through REMS. The key is showing that standard therapies have truly been inadequate and that the cardiac monitoring plan is robust."

Appeals Process in Georgia

Internal Appeals (First Step)

Timeline: Must file within 180 days of denial letter Process: Submit through BCBS member portal or by mail Decision timeframe: 30 days for standard, 72 hours for expedited

External Review (If Internal Appeal Fails)

Georgia law provides for independent external review through the Georgia Department of Insurance.

Key deadlines:

  • File within 60 days of final internal denial
  • No cost to the consumer
  • Decision typically within 30 business days

To request external review:

  1. Complete the external review application
  2. Submit to GA Office of Commissioner of Insurance and Fire Safety
  3. Include all relevant medical records
  4. Await assignment to independent review organization

Contact for help: Georgia DOI Consumer Services: 1-800-656-2298

Renewal and Re-Authorization

Timing Your Renewal

  • Start renewal process 30-45 days before current authorization expires
  • Most Fintepla authorizations are approved for 6-12 months

Required Documentation for Renewal

✓ Current seizure frequency data ✓ Most recent echocardiogram (within 6 months) ✓ Updated Patient Status Form from REMS ✓ Documentation of clinical benefit ✓ Continued specialist oversight

Evidence of Clinical Benefit

Document improvements such as:

  • Percentage reduction in seizure frequency
  • Decreased seizure severity
  • Reduced emergency department visits
  • Improved quality of life measures

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Step therapy not completed Document failed trials of required generics Detailed medication history with dates and outcomes
Missing REMS enrollment Complete REMS registration REMS confirmation and Patient Status Form
Insufficient diagnosis documentation Provide specialist confirmation Neurology consultation notes with specific syndrome diagnosis
Age requirements not met Verify patient age and FDA labeling Birth certificate or medical record confirmation
Drug interaction concerns Address specific interactions Medication reconciliation and safety assessment

FAQ

Q: How long does BCBS prior authorization take in Georgia? A: Standard requests must be processed within 15 calendar days. Expedited requests are processed within 72 hours for urgent medical situations.

Q: What if Fintepla is not on my formulary? A: You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. This requires additional clinical documentation.

Q: Can I request an expedited appeal? A: Yes, if delays in treatment could pose serious risk to your health. Your prescriber must document the urgent medical need.

Q: Does step therapy apply if I've tried medications outside Georgia? A: Yes, medication trials from other states count toward step therapy requirements. Ensure you have documentation from all treating physicians.

Q: What specialty pharmacies can dispense Fintepla in Georgia? A: Only REMS-certified specialty pharmacies in your BCBS network. Most commonly CVS Specialty, but verify with your specific plan.

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

Quick Reference Checklist

Before Starting

  • Verify BCBS plan type and formulary status
  • Identify required specialty pharmacy
  • Confirm prescriber REMS certification

Documentation to Gather

  • Confirmed Dravet syndrome or LGS diagnosis
  • Prior medication trial documentation (2-3 generics minimum)
  • Baseline echocardiogram report
  • REMS enrollment confirmation
  • Current seizure frequency data

Submission Steps

  • Complete plan-specific PA form
  • Submit via electronic portal or fax
  • Save confirmation number
  • Schedule follow-up call in 3-5 business days

If Denied

  • Review denial reason carefully
  • Gather additional requested documentation
  • Consider peer-to-peer review
  • File appeal within required timeframe

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and creates evidence-backed appeals tailored to each payer's specific requirements, increasing approval rates while reducing administrative burden.

If you need additional support navigating the prior authorization process for Fintepla, Counterforce Health's specialized tools can help streamline your appeal and improve your chances of coverage approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions are made by individual payers based on specific plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and requirements may change; verify current information with your insurer.

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