By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (Fenfluramine) Covered by Cigna in Florida: Prior Authorization, Appeals & Exception Strategies

Answer Box: Getting Fintepla (Fenfluramine) Covered by Cigna in Florida

Fastest path: Submit a complete prior authorization through your neurologist with diagnosis documentation (Dravet syndrome or Lennox-Gastaut syndrome), failed alternative ASM trials, and REMS enrollment proof. Most Cigna Florida plans require PA and may need formulary exceptions for this specialty drug.

First step today: Call Cigna member services at the number on your insurance card to confirm your plan's formulary status for Fintepla and request the current prior authorization form. Your neurologist's office will handle the clinical submission.

Timeline: Standard PA decisions take 15 business days; appeals have 180-day filing windows in Florida with 30-60 day review periods.

Table of Contents

When Fintepla Alternatives Make Sense

If Cigna initially denies Fintepla (fenfluramine) or places it on a restricted formulary tier, understanding when alternatives might be appropriate—and when they're not—helps you make informed decisions about next steps.

Clinical scenarios where alternatives may work:

  • You haven't yet tried all of Cigna's preferred antiseizure medications (ASMs) for Dravet syndrome or Lennox-Gastaut syndrome
  • Current seizure control is partial but stable, allowing time for a careful medication trial
  • Cardiac monitoring requirements for Fintepla pose logistical challenges in your area

When to push for Fintepla specifically:

  • Previous trials of multiple preferred ASMs have failed or caused intolerable side effects
  • You're currently on Fintepla with good seizure control (renewal situation)
  • Cardiac monitoring is already established and results are normal
  • Other family members have responded well to Fintepla for the same condition
From our advocates: We've seen families successfully get Fintepla approved after initially trying one or two formulary alternatives, especially when they kept detailed seizure diaries during the alternative trials. This documentation later became crucial evidence for medical necessity appeals.

Typical Formulary Alternatives by Class

Cigna's step therapy typically requires trials of these categories before approving Fintepla:

First-Line Preferred ASMs for Dravet Syndrome

  • Valproate (Depakote, generic) - Often first-choice; requires liver function monitoring
  • Clobazam (Onfi, generic) - May require separate prior authorization depending on plan
  • Stiripentol (Diacomit) - Specialty drug but often preferred over Fintepla

Alternative Options for LGS

  • Rufinamide (Banzel) - Prior authorization required but typically covered
  • Topiramate (Topamax, generic) - Usually formulary without PA
  • Lamotrigine (Lamictal, generic) - Common first-line choice

Other Cigna-Preferred Specialty ASMs

  • Cannabidiol (Epidiolex) - Requires PA but often approved before Fintepla
  • Levetiracetam (Keppra, generic) - Widely formulary
  • Felbamate (Felbatol) - For severe cases with monitoring requirements

Pros and Cons Overview

Formulary Alternatives: Access Considerations

Advantages of trying alternatives first:

  • Faster approval process (many are formulary without PA)
  • Lower copays on most insurance tiers
  • Established monitoring protocols at most neurology practices
  • No REMS enrollment requirements for most options

Potential drawbacks:

  • May delay access to potentially more effective treatment
  • Some alternatives (like stiripentol) still require specialty pharmacy coordination
  • Risk of seizure worsening during medication switches
  • Time spent on ineffective trials could impact long-term seizure control

Testing and Monitoring Requirements

Medication Required Monitoring Frequency Coverage Impact
Fintepla Echocardiogram via REMS Every 6 months May require cardiology PA
Valproate Liver function tests Every 6 months Usually covered
Clobazam Drug levels (optional) As needed Usually covered
Stiripentol Drug interactions Ongoing May require PA
Epidiolex Liver function tests Every 3 months initially Usually covered

Formulary Exception Strategy

When to Request an Exception

File a formulary exception request when:

  1. Non-formulary status: Fintepla isn't listed on your specific Cigna plan's drug list
  2. Step therapy requirements: You've tried required alternatives without success
  3. Quantity limitations: Prescribed dose exceeds plan limits
  4. Tier placement: Drug is placed on highest cost-sharing tier

Evidence That Strengthens Your Case

Clinical documentation to gather:

  • Diagnosis confirmation (genetic testing for Dravet, EEG findings for LGS)
  • Detailed seizure logs showing frequency and severity before/after treatments
  • Documentation of failed alternative trials with specific reasons (ineffective, side effects, contraindications)
  • Current response to Fintepla if already prescribed

Supporting medical literature:

  • FDA prescribing information for approved indications
  • Recent clinical trials showing efficacy in your specific syndrome
  • Specialty society guidelines (American Epilepsy Society, Child Neurology Society)

Switching Logistics and Coordination

Working with Express Scripts/Accredo

Most Cigna specialty drugs, including many ASMs, are dispensed through Express Scripts specialty pharmacy network. Here's how to coordinate switches:

Before starting an alternative:

  1. Verify the new drug's pharmacy network (specialty vs. retail)
  2. Confirm prior authorization status and submit PA before current supply runs low
  3. Request overlapping supplies during cross-taper periods
  4. Set up automatic refills and delivery scheduling

During medication transitions:

  • Keep detailed seizure and side effect logs
  • Maintain regular contact with your neurologist's office
  • Don't alter prescribed taper schedules without medical guidance
  • Have rescue medications readily available

REMS Coordination

If switching from or to Fintepla, coordinate REMS enrollment:

  • Switching away from Fintepla: Continue required cardiac monitoring per REMS until completion
  • Switching to Fintepla later: Ensure prescriber and patient REMS enrollment before PA submission

Re-trying for Fintepla Later

What to Document During Alternative Trials

Keep comprehensive records that will support a future Fintepla request:

Seizure documentation:

  • Baseline seizure frequency before starting alternative
  • Weekly seizure counts during trial period (minimum 30-90 days per drug)
  • Seizure types and severity changes
  • Emergency department visits or hospitalizations

Side effect tracking:

  • Daily or weekly side effect logs
  • Impact on daily activities, school, or work
  • Sleep disturbances, appetite changes, mood effects
  • Any laboratory abnormalities

Efficacy assessment:

  • Percentage change in seizure frequency
  • Quality of life improvements or deterioration
  • Caregiver burden changes
  • Functional status changes

Building Your Case for Medical Necessity

After documenting failed alternatives, your neurologist can submit a stronger Fintepla PA that includes:

  • Complete trial history with quantified outcomes
  • Specific reasons each alternative was inadequate
  • Risk-benefit analysis favoring Fintepla
  • Updated cardiac clearance for REMS enrollment

Counterforce Health helps families and clinicians organize this documentation into compelling prior authorization requests and appeals, turning insurance denials into targeted, evidence-backed approvals.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who does it: Patient/caregiver
Action: Call Cigna member services (number on insurance card)
Ask for: Current formulary status, PA requirements, preferred alternatives
Timeline: Same day

2. Gather Clinical Documentation

Who does it: Neurologist's office
Documents needed: Diagnosis confirmation, seizure logs, prior medication trials
Submit via: Cigna provider portal or PA fax line
Timeline: 3-5 business days to compile

3. Submit Complete PA Request

Who does it: Prescriber
Required elements: Medical necessity letter, clinical notes, REMS enrollment proof
Timeline: 15 business days for standard review

4. Request Peer-to-Peer if Denied

Who does it: Prescriber
Action: Contact Cigna utilization management for clinical discussion
Timeline: Usually available within 72 hours of denial

5. File Internal Appeal

Who does it: Patient or prescriber
Deadline: 180 days from denial notice
Submit to: Cigna appeals department (address on denial letter)
Timeline: 30 days for prospective services, 60 days for retrospective

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
"Not medically necessary" Submit detailed seizure logs and failed alternative trials Clinical notes, seizure diary, medication history
"Step therapy not met" Document contraindications or failures of required alternatives Prescriber attestation, adverse event reports
"REMS not enrolled" Complete prescriber and patient REMS enrollment REMS confirmation, baseline echocardiogram
"Diagnosis not supported" Provide genetic testing or EEG confirmation Laboratory results, specialist consultation notes
"Quantity exceeds limits" Justify weight-based dosing per FDA label Height/weight documentation, dosing calculations

Appeals Playbook for Cigna in Florida

Internal Appeal Process

First Level Internal Appeal:

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for prospective services, 60 days for retrospective
  • Submit to: Address provided in denial letter or Cigna member portal
  • Required: Written appeal request, supporting clinical documentation

Second Level Internal Appeal:

  • Automatic: If first level is denied
  • Timeline: Additional 30-60 days
  • Reviewer: Different clinical reviewer than first level

External Review in Florida

After exhausting internal appeals, Florida residents can request external review:

Eligibility:

  • Completed internal appeal process
  • Denial based on medical necessity or experimental/investigational determination
  • Service/medication is covered benefit under plan

How to request:

Expedited Review Process

For urgent situations where delay could seriously jeopardize health:

  • Request simultaneously: Internal and external expedited review
  • Timeline: 72 hours for urgent external review
  • Documentation required: Physician statement of urgency

FAQ

How long does Cigna PA take in Florida?
Standard prior authorization decisions are made within 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Fintepla is non-formulary on my plan?
Request a formulary exception with your PA submission. Include documentation showing why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal?
Yes, if your physician documents that delay in treatment could seriously jeopardize your health or ability to regain maximum function.

Does step therapy apply if I tried alternatives outside Florida?
Yes, Cigna will consider documented trials from other states or insurance plans if properly documented in medical records.

What's the success rate for Fintepla appeals?
While specific rates aren't published, appeals with comprehensive clinical documentation and clear medical necessity rationale have higher success rates, particularly for rare disease treatments.

Can I continue current Fintepla while appealing?
If you're currently on Fintepla, request continuation of coverage during the appeal process. Some plans provide interim coverage for ongoing treatments.

Who can help me navigate this process?
Your neurologist's office, Cigna member services, and Florida's Insurance Consumer Helpline (1-877-693-5236) can provide assistance. Counterforce Health specializes in turning insurance denials into successful approvals for complex medications like Fintepla.

What if my appeal is denied?
After exhausting internal appeals, you can request external review through the Florida Department of Financial Services. You may also file a complaint with Florida's Division of Consumer Services.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and procedural requirements for each payer.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage decisions. For assistance with insurance complaints in Florida, contact the Division of Consumer Services at 1-877-693-5236.

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