By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (fenfluramine) Covered by Blue Cross Blue Shield in Washington: Appeals Process, REMS Requirements, and State Protections

Answer Box: Getting Fintepla Covered by Blue Cross Blue Shield in Washington

Fintepla (fenfluramine) requires prior authorization from Blue Cross Blue Shield with mandatory REMS enrollment and baseline echocardiography. To get approval: (1) Complete REMS enrollment at FinteplaREMS.com with baseline ECHO, (2) Submit PA with diagnosis confirmation (Dravet G40.83 or LGS G40.82) and documentation of 2-3 failed antiseizure medications, (3) If denied, file internal appeal within 180 days, then external review through Washington's Office of Insurance Commissioner within 120 days. Washington's strong consumer protections include independent medical review and binding decisions on insurers.

Table of Contents

Why Washington State Rules Matter

Washington state provides some of the strongest patient protections in the nation for insurance appeals, particularly for specialty medications like Fintepla. Under RCW 48.43.535, you have the right to independent external review after exhausting internal appeals, with decisions that are binding on Blue Cross Blue Shield.

The state's Office of Insurance Commissioner (OIC) actively advocates for consumers, and Washington's new Specialist Care Access Act (effective March 2025) specifically targets high reversal rates for specialist medication denials. This creates a favorable environment for appeals involving rare seizure medications prescribed by neurologists.

Note: These protections apply to fully-insured Blue Cross Blue Shield plans. If you have an employer self-funded plan, federal ERISA rules may apply instead—check your Summary Plan Description or contact the U.S. Department of Labor.

Prior Authorization Requirements

Blue Cross Blue Shield requires prior authorization for Fintepla across all plans. Based on similar BCBS policies nationwide, you'll need to document:

Coverage Requirements Table

Requirement Documentation Needed Where to Find It
Diagnosis Dravet syndrome (G40.83) or Lennox-Gastaut syndrome (G40.82) Neurologist records, genetic testing for Dravet
Age 2+ years Birth certificate if challenged
Prior Therapy Failure of 2-3 antiseizure medications Treatment history with dates, doses, discontinuation reasons
REMS Enrollment Completed enrollment + baseline ECHO FinteplaREMS.com confirmation
Prescriber Neurologist or epilepsy specialist Provider credentials and attestation letter

Contact your Blue Cross Blue Shield member services to request the specific prior authorization form for your plan, as requirements may vary between Premera Blue Cross, Regence BlueShield, and other Washington Blues.

REMS Enrollment Process

Fintepla requires mandatory Risk Evaluation and Mitigation Strategy (REMS) enrollment before treatment. This cannot be bypassed and is often a primary reason for denials.

Step-by-Step REMS Enrollment

  1. Prescriber Enrollment (Done by your doctor)
    • Complete Prescriber Enrollment Form at FinteplaREMS.com
    • Pass knowledge assessment and training
    • Counsel patient on heart valve and lung artery risks
  2. Patient Enrollment (Done with your doctor)
    • Complete Patient Enrollment Form
    • Schedule baseline echocardiogram (ECHO)
    • Submit ECHO results to REMS program
  3. Ongoing Requirements
    • ECHO every 6 months during treatment
    • ECHO 3-6 months after stopping Fintepla
    • Report any heart or lung symptoms immediately
Tip: Complete REMS enrollment before submitting your Blue Cross Blue Shield prior authorization. Missing REMS documentation is the most common reason for denial.

The REMS program can be reached at 1-833-568-6198 (fax) or by mail at 1710 N Shelby Oaks Dr, Suite 3, Memphis, TN 38134.

Step Therapy and Medical Exceptions

Blue Cross Blue Shield typically requires trial and failure of multiple generic antiseizure medications before approving Fintepla. Based on similar BCBS policies, you'll likely need to document failure of at least three medications from this list:

  • Clonazepam, diazepam, divalproex
  • Gabapentin, lacosamide, lamotrigine
  • Levetiracetam, oxcarbazepine, phenobarbital
  • Phenytoin, pregabalin, topiramate
  • Valproic acid, zonisamide

Medical Exception Criteria

You can request a step therapy exception if you have:

  • Contraindications to required medications
  • Previous intolerance with documented adverse effects
  • Clinical reasons why alternatives won't work (e.g., drug interactions, medical conditions)
  • Prior success with Fintepla on another plan

Document each medication trial with specific dates, doses, duration of treatment, and reason for discontinuation (lack of efficacy, side effects, contraindications).

Appeals Process in Washington

If Blue Cross Blue Shield denies your Fintepla prior authorization, Washington law provides a structured appeals process with specific timelines and protections.

Internal Appeals (Required First Step)

  1. File Within 180 Days of denial notice
  2. Submit to Blue Cross Blue Shield appeals department
  3. Include New Information not in original request
  4. Request Expedited Review if urgent (72-hour decision)
  5. Get Decision within 30 days for standard appeals

Required Documents for Appeal

  • Original denial letter
  • Medical necessity letter from prescriber
  • Complete treatment history and failed medications
  • REMS enrollment confirmation
  • Supporting medical literature
  • Patient impact statement
Clinician Corner: Medical necessity letters should include: (1) specific diagnosis with ICD-10 code, (2) prior antiseizure medications tried with dates and outcomes, (3) contraindications to alternatives, (4) expected clinical benefits of Fintepla, (5) REMS compliance plan, and (6) monitoring schedule.

External Review Rights

Washington's external review process under RCW 48.43.535 provides independent medical review when internal appeals fail.

External Review Timeline

Step Timeline Action Required
File Request Within 120 days of final internal denial Submit to Blue Cross Blue Shield or OIC
Case Assignment 3 business days Insurer sends records to Independent Review Organization (IRO)
Your Input 5 business days Submit additional information to IRO
IRO Decision 15-20 days Binding decision on Blue Cross Blue Shield
Expedited 72 hours For urgent health situations

The IRO decision is binding on Blue Cross Blue Shield—if they approve Fintepla, your insurer must cover it.

Continuity of Care Protections

Washington's continuity of care regulations under WAC 284-170 protect patients during provider network changes or formulary transitions.

If your neurologist leaves Blue Cross Blue Shield's network or Fintepla moves to a non-covered tier:

  • 90 days continued coverage for ongoing specialty care
  • Bridge prescriptions during prior authorization for alternatives
  • Case-by-case evaluation for established treatments

Contact Blue Cross Blue Shield member services at 1-888-263-2583 to request continuity coverage if your situation qualifies.

Common Denial Reasons & Solutions

Denial Reason How to Fix It
Missing REMS enrollment Complete enrollment at FinteplaREMS.com and submit confirmation
Insufficient prior trials Document 2-3 failed antiseizure medications with dates and reasons
Diagnosis not supported Include genetic testing (Dravet) or EEG results (LGS)
Not medically necessary Submit medical necessity letter citing FDA approval and seizure frequency
Drug interactions Provide medication reconciliation and safety monitoring plan

Counterforce Health specializes in turning these denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals that address each specific denial reason.

Cost Assistance Programs

While pursuing insurance coverage, several programs can help with Fintepla costs:

  • UCB Cares Patient Assistance: Income-based free medication program
  • UCB Copay Card: May reduce copays to $0-25 for eligible patients
  • Foundation Support: Organizations like HealthWell Foundation offer grants for rare disease medications

The typical cash price for Fintepla is approximately $1,595 for a 30-mL bottle, with total monthly costs varying by prescribed dose.

When to Contact State Regulators

Contact the Washington Office of Insurance Commissioner if:

  • Blue Cross Blue Shield violates appeal deadlines
  • You need help understanding your rights
  • Internal appeals are improperly handled
  • You want assistance with external review

OIC Consumer Advocacy: 1-800-562-6900
Online Complaints: insurance.wa.gov

The OIC investigates procedural violations and can expedite reviews for urgent cases.

FAQ

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard prior authorization decisions must be made within 5 calendar days. Expedited reviews for urgent cases are decided within 72 hours.

What if Fintepla isn't on my formulary? You can request a formulary exception with medical necessity documentation. If denied, appeal through internal and external review processes.

Can I get expedited appeals for seizure medications? Yes, if your health could be in serious jeopardy without the medication. Document seizure frequency and risk of status epilepticus.

Do step therapy requirements apply if I tried medications in another state? Yes, document all prior trials regardless of where they occurred. Include pharmacy records and physician notes from previous providers.

What happens during external review? An independent medical expert reviews your case and makes a binding decision on Blue Cross Blue Shield. The reviewer specializes in your condition and isn't employed by your insurer.

How much does external review cost? External review is free to you. Washington law prohibits charging patients for this process.

This guide provides educational information about insurance appeals and is not medical advice. Consult your healthcare provider about treatment decisions and contact the Washington Office of Insurance Commissioner at 1-800-562-6900 for personalized assistance with appeals.

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements by analyzing denial letters, payer policies, and clinical evidence to create targeted appeals that turn denials into approvals. Our platform specializes in rare disease medications like Fintepla, ensuring that appeals meet each payer's specific requirements while leveraging state protections like Washington's robust external review process.

Sources & Further Reading

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