By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (fenfluramine) Covered by Cigna in Virginia: Prior Authorization, Appeals & REMS Requirements

Answer Box: Getting Fintepla Covered by Cigna in Virginia

Cigna requires prior authorization for Fintepla (fenfluramine) in Virginia with strict REMS enrollment and echocardiography requirements. Here's your fastest path to approval:

  1. Ensure REMS compliance: Both prescriber and patient must be enrolled in the Fintepla REMS program before submission
  2. Gather required documentation: Recent echocardiogram (≤6 months), seizure logs, neurologist consultation notes, and proof of at least two failed anti-seizure medications
  3. Submit 60-90 days early: Begin renewal process well before current authorization expires through Cigna's provider portal

First step today: Contact your neurologist to confirm REMS enrollment status and schedule your required echocardiogram if it's been more than 6 months.

Table of Contents

  1. Cigna Plan Types & Coverage Implications
  2. Fintepla Formulary Status & Tier Placement
  3. Prior Authorization & Step Therapy Requirements
  4. REMS Program & Specialty Pharmacy Process
  5. Cost-Share Basics
  6. Step-by-Step: Fastest Path to Approval
  7. Common Denial Reasons & Solutions
  8. Appeals Process in Virginia
  9. FAQ
  10. Sources & Further Reading

Cigna Plan Types & Coverage Implications

Understanding your specific Cigna plan type affects how you access Fintepla and specialist care in Virginia:

HMO Plans:

  • Require referrals from your Primary Care Provider (PCP) to see neurologists
  • Coverage limited to in-network providers only
  • Prior authorization still required for Fintepla regardless of referral status

PPO Plans:

  • No referral needed for specialist visits
  • Can see out-of-network providers at higher cost
  • Same prior authorization requirements apply

EPO Plans:

  • No referrals required for specialists
  • Coverage limited to in-network providers only
  • Most common plan type for Cigna individual market in Virginia
Note: All Cigna plan types in Virginia require prior authorization for Fintepla, but HMO members need PCP referrals before seeing neurologists for initial consultations.

Fintepla Formulary Status & Tier Placement

Fintepla is classified as a Tier 4 specialty medication on Cigna's 2025 formulary, which means:

  • Higher cost-sharing compared to generic medications
  • Specialty pharmacy dispensing required (typically through Express Scripts/Accredo)
  • Mandatory prior authorization for all new prescriptions and renewals
  • Annual quantity limits may apply based on FDA-approved dosing

Alternative Anti-Seizure Medications

Before approving Fintepla, Cigna requires documentation of trials with at least two of these preferred agents:

  • Clobazam (Onfi)
  • Cannabidiol (Epidiolex)
  • Felbamate
  • Lamotrigine
  • Rufinamide
  • Topiramate
  • Valproic acid
  • Levetiracetam
  • Vigabatrin

Prior Authorization & Step Therapy Requirements

Coverage at a Glance

Requirement Details Documentation Needed Source
Age limit ≥2 years old Birth certificate or medical records Cigna PA Policy
Diagnosis Dravet or Lennox-Gastaut syndrome ICD-10 codes, genetic testing results Cigna PA Policy
Step therapy ≥2 failed ASMs Medication history, trial documentation Cigna PA Policy
Specialist Neurologist prescription/consultation Referral or consultation notes Cigna PA Policy
REMS enrollment Patient and prescriber certified REMS confirmation documentation FDA REMS
Cardiac monitoring Echocardiogram ≤6 months Echo report with normal findings FDA REMS

REMS Program & Specialty Pharmacy Process

The Fintepla REMS program is mandatory due to cardiac risks. Here's what you need to know:

Patient REMS Requirements

  • Complete REMS enrollment before first prescription
  • Undergo baseline echocardiogram
  • Schedule follow-up echos every 6 months
  • Maintain current enrollment status for renewals

Specialty Pharmacy Dispensing

Cigna typically uses Express Scripts/Accredo for Fintepla dispensing. The pharmacy must:

  • Verify REMS enrollment for every fill
  • Confirm prescriber certification
  • Maintain detailed dispensing records
  • Follow Virginia state pharmacy regulations for controlled substance delivery
Tip: Contact the Fintepla REMS program at 1-877-964-3649 to verify your enrollment status before submitting prior authorization requests.

Cost-Share Basics

As a Tier 4 specialty medication, Fintepla typically involves:

  • Deductible: May apply before coverage begins
  • Coinsurance: Usually 25-40% of drug cost after deductible
  • Out-of-pocket maximum: Annual limit on your total costs

Cost-saving options to explore:

Note: This is educational information only. Consult your specific plan documents for exact cost-sharing details.

Step-by-Step: Fastest Path to Approval

For New Prescriptions

  1. Confirm diagnosis documentation (Patient/Family)
    • Genetic testing results for Dravet syndrome
    • EEG reports confirming seizure patterns
    • Timeline: Complete before neurologist visit
  2. Document prior medication trials (Neurologist)
    • At least 2 failed anti-seizure medications
    • Include dates, dosages, reasons for discontinuation
    • Timeline: Gather during consultation
  3. Complete REMS enrollment (Patient + Prescriber)
    • Visit www.FinteplaREMS.com
    • Submit required forms and training
    • Timeline: 2-5 business days for approval
  4. Obtain baseline echocardiogram (Patient)
    • Schedule with cardiologist or imaging center
    • Ensure report shows no contraindications
    • Timeline: 1-2 weeks for appointment and results
  5. Submit prior authorization (Prescriber/Office Staff)
    • Use Cigna provider portal or fax submission
    • Include all required documentation
    • Timeline: Submit 60-90 days before needed
  6. Follow up on determination (Patient/Office)
    • Check status within 5-7 business days
    • Request expedited review if urgent
    • Timeline: 15 business days for standard review
  7. Coordinate specialty pharmacy (Patient)
    • Work with approved Cigna specialty pharmacy
    • Verify REMS compliance before dispensing
    • Timeline: 3-5 days after approval

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing REMS documentation Submit current enrollment verification REMS confirmation letter
Inadequate step therapy Provide detailed trial history Medication records with dates, doses, outcomes
Outdated echocardiogram Schedule new cardiac evaluation Echo report dated ≤6 months
Non-specialist prescriber Obtain neurologist consultation Consultation notes or co-signature
Insufficient medical necessity Submit comprehensive clinical narrative Seizure logs, functional assessments, treatment goals

Appeals Process in Virginia

If Cigna denies your Fintepla request, Virginia provides robust appeal rights:

Internal Appeals (First Level)

  • Timeline: Must file within 180 days of denial
  • Process: Submit written appeal with additional evidence
  • Decision: 30 days for standard, 72 hours for expedited

External Review (Independent)

After exhausting internal appeals, you can request external review through the Virginia State Corporation Commission Bureau of Insurance:

  • Timeline: 120 days from final internal denial to file
  • Cost: Free to consumers
  • Process: Independent medical review by qualified specialists
  • Decision: 45 days standard, 72 hours expedited

Contact Information:

From our advocates: We've seen many Fintepla denials overturned on appeal when families provide comprehensive seizure logs and detailed documentation of medication failures. The key is showing how previous treatments didn't control seizures despite appropriate trials, and including current REMS compliance documentation.

When to Request Expedited Review

Request expedited appeals if:

  • Current seizure control is inadequate and poses immediate risk
  • Patient is experiencing increased seizure frequency
  • Delay could result in serious health consequences

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and crafting evidence-backed rebuttals aligned to each plan's requirements. Our platform helps patients and clinicians navigate complex prior authorization requirements and appeals processes more effectively. Learn more about our services.

FAQ

How long does Cigna prior authorization take for Fintepla in Virginia? Standard reviews take up to 15 business days. Expedited reviews (for urgent medical need) are decided within 72 hours.

What if Fintepla is non-formulary on my Cigna plan? You can request a formulary exception by demonstrating medical necessity and providing clinical justification for why preferred alternatives aren't appropriate.

Can I appeal if I'm already taking Fintepla and coverage is discontinued? Yes. Submit an appeal with current seizure control data and evidence of ongoing medical necessity. Consider requesting continuation of benefits during the appeal process.

Does step therapy apply if I tried medications in another state? Yes, medication trials from any location count toward step therapy requirements. Provide complete documentation from previous providers.

What counts as "adequate trial" for step therapy purposes? Generally, therapeutic doses for sufficient duration (usually 2-4 weeks unless limited by side effects) with documented outcomes.

How often do I need echocardiograms for continued coverage? Every 6 months as required by the REMS program. Schedule proactively to avoid coverage interruptions.

Can my primary care doctor prescribe Fintepla? Cigna requires prescription by or in consultation with a neurologist. PCPs may need specialist involvement for approval.

What if my appeal is denied by Virginia's external review? The external review decision is final and binding. However, you may still have legal options or could reapply with new clinical evidence.

This comprehensive guide provides the framework for successfully navigating Cigna's Fintepla coverage requirements in Virginia. For personalized assistance with complex cases, Counterforce Health offers specialized support in transforming denials into approved coverage through targeted, evidence-based appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current information with Cigna and consult healthcare providers for medical decisions. For assistance with insurance appeals and prior authorization challenges, contact the Virginia State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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