By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (fenfluramine) Covered by Humana in New York: Complete Guide with Forms and Appeals

Answer Box: Getting Fintepla Covered by Humana in New York

Fintepla (fenfluramine) requires prior authorization from Humana for Dravet syndrome and Lennox-Gastaut syndrome patients. The fastest path to approval involves three critical steps: 1) Complete REMS enrollment for both prescriber and patient, 2) Submit baseline echocardiogram showing cardiac safety, and 3) File prior authorization through Availity portal or fax to 877-486-2621 with medical necessity documentation. If denied, New York residents with Medicare Advantage must use federal Medicare appeals (not NY DFS external appeals). Start today by verifying your Humana plan covers specialty medications and initiating REMS enrollment at FinteplaREMS.com.

Table of Contents

  1. Verify Your Humana Plan Coverage
  2. REMS Enrollment Requirements
  3. Prior Authorization Forms and Submission
  4. Specialty Pharmacy Network Setup
  5. Common Denial Reasons and Solutions
  6. Appeals Process for Humana Medicare Advantage
  7. Cost Assistance Programs
  8. New York Resources and Support
  9. FAQ

Verify Your Humana Plan Coverage

Before starting the approval process, confirm your specific Humana plan covers Fintepla. Most Humana Medicare Advantage plans require prior authorization for this specialty medication.

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all plans Humana formulary Humana PA Guidelines
Formulary Status Specialty tier Plan documents Humana Drug Lists
Step Therapy May require failed trials PA form Verify with plan
Age Restriction 2 years and older FDA label FDA Prescribing Information
REMS Required Mandatory enrollment REMS program Fintepla REMS

What to Do First:

  • Call the number on your Humana ID card to verify specialty drug coverage
  • Ask specifically about Fintepla's formulary tier and any quantity limits
  • Request current prior authorization requirements for your plan year

REMS Enrollment Requirements

Fintepla is only available through a Risk Evaluation and Mitigation Strategy (REMS) program due to cardiac risks. Both prescriber and patient must enroll before any prescription can be filled.

Step-by-Step REMS Enrollment:

  1. Prescriber Enrollment
    • Register at FinteplaREMS.com
    • Complete required training modules
    • Obtain REMS certification number
  2. Patient Enrollment
    • Complete Patient Enrollment Form
    • Schedule baseline echocardiogram
    • Submit forms through prescriber or directly to REMS
  3. Baseline Echocardiogram Requirements
    • Must show no mild or greater aortic regurgitation
    • No moderate or greater mitral regurgitation
    • Pulmonary arterial systolic pressure ≤35 mm Hg
    • No significant cardiac abnormalities
Note: REMS enrollment certificates for both prescriber and patient must be included in your Humana prior authorization submission.

Prior Authorization Forms and Submission

Humana offers multiple submission methods for Fintepla prior authorization requests.

Fastest Path: Online Submission

  1. Availity Portal (Recommended)
    • Register at Availity.com
    • Complete medication-specific questionnaire
    • May receive real-time decision
    • Upload supporting documents directly
  2. Required Documentation:
    • Completed "Request for Medicare Prescription Drug Coverage Determination" form
    • REMS enrollment certificates (prescriber and patient)
    • Baseline echocardiogram report
    • Clinical notes supporting diagnosis (Dravet or Lennox-Gastaut syndrome)
    • Documentation of prior anti-seizure medication trials and outcomes
    • Current seizure frequency logs

Alternative: Fax Submission

  • Medicare Advantage: Fax to 877-486-2621
  • Include cover sheet with patient name, Humana ID, and "Fintepla Prior Authorization"
  • Confirm receipt by calling provider services at 866-461-7273

Timeline Expectations:

  • Standard decision: 30 days for pre-service requests
  • Expedited review: 72 hours (if urgent medical need documented)

Specialty Pharmacy Network Setup

Fintepla can only be dispensed by REMS-certified specialty pharmacies. Humana members have access to in-network specialty pharmacies that participate in the REMS program.

Steps to Set Up Specialty Pharmacy:

  1. Find REMS-Certified Pharmacy
    • Use pharmacy locator at FinteplaREMS.com
    • Verify Humana network participation
    • Confirm they can coordinate with your location in New York
  2. Pharmacy Requirements:
    • Must verify prescriber REMS certification
    • Confirm patient REMS enrollment
    • Maintain detailed dispensing records
    • Report to REMS program as required
  3. Transfer Existing Prescriptions:
    • Contact new specialty pharmacy
    • Provide current pharmacy information
    • Ensure continuity of care during transition

Common Denial Reasons and Solutions

Understanding typical denial reasons helps prevent delays and strengthens appeals.

Denial Reason Solution Required Documentation
Missing REMS enrollment Submit certificates Prescriber and patient REMS confirmations
Incomplete cardiac monitoring Provide echo results Baseline and follow-up echocardiograms
Diagnosis not supported Submit clinical notes ICD-10 codes, seizure logs, EEG results
Step therapy not met Document prior failures Medication trial history with dates and outcomes
Drug interactions Provide safety assessment Current medication list, contraindication review

From Our Advocates: We've seen cases where initial denials were overturned simply by resubmitting with complete REMS documentation. One family's approval was delayed three weeks because the baseline echocardiogram report wasn't included in the original submission. Always double-check that all required documents are attached before submitting.

Appeals Process for Humana Medicare Advantage

Important: New York residents with Humana Medicare Advantage plans must use the federal Medicare appeals process, not the New York Department of Financial Services external appeal system.

Step-by-Step Medicare Appeals:

  1. Internal Plan Appeal (Reconsideration)
    • File within 60 days of denial notice
    • Submit through Humana member portal or by mail
    • Include additional medical evidence
    • Request expedited review if urgent (72-hour decision)
  2. Independent Review Entity (IRE)
    • Available after internal appeal denial
    • Conducted by Medicare-contracted reviewers
    • Follow instructions in denial letter
    • Contact 1-800-MEDICARE for assistance
  3. Further Appeal Levels
    • Administrative Law Judge
    • Medicare Appeals Council
    • Federal District Court

Key Resources:

Cost Assistance Programs

Even with insurance approval, Fintepla can be expensive. Several programs help reduce out-of-pocket costs.

Financial Assistance Options:

  1. UCB Patient Assistance Programs
    • Visit Fintepla.com cost page for current programs
    • May include copay assistance and patient assistance programs
    • Eligibility varies by insurance type and income
  2. Foundation Support
    • Research rare disease foundations
    • Some provide grants for seizure medications
    • Applications typically require financial documentation
  3. Medicare Extra Help
    • Low-income subsidy for prescription drugs
    • Apply through Social Security Administration
    • Can significantly reduce copayments

New York Resources and Support

New York offers robust consumer protection and assistance programs for insurance issues.

State Support Services:

  1. Community Health Advocates (CHA)
    • Free insurance counseling
    • Helpline: 888-614-5400
    • Assists with appeals and denials
  2. New York State Department of Financial Services
    • Consumer assistance for commercial insurance issues
    • File complaints about insurer practices
    • Note: Does not handle Medicare Advantage appeals
  3. Medicare Rights Center
    • National helpline: 800-333-4114
    • Specializes in Medicare issues
    • Free counseling and advocacy

When to Contact State Regulators:

  • Humana fails to follow proper procedures
  • Unreasonable delays in processing
  • Violations of member rights

FAQ

How long does Humana prior authorization take for Fintepla in New York? Standard decisions take up to 30 days. Expedited reviews are completed within 72 hours if urgent medical need is documented.

What if Fintepla is not on my Humana formulary? You can request a formulary exception by submitting a prior authorization with medical necessity documentation. Include evidence that formulary alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if your health could be jeopardized by delay. Your prescriber must certify the urgency in writing.

Does step therapy apply if I tried medications outside New York? Yes, document all prior medication trials regardless of where they occurred. Include dates, dosages, duration, and reasons for discontinuation.

What happens if I move within New York while on Fintepla? Notify Humana of your address change. Ensure your new area has access to REMS-certified specialty pharmacies.

How often do I need echocardiograms while on Fintepla? Every 6 months during treatment, plus 3-6 months after discontinuation. Results must be reported to the REMS program.

Can a family member help with my appeal? Yes, but you must provide written authorization for them to act on your behalf. Include this with your appeal submission.

What if Humana denies my expedited appeal? You can immediately request Independent Review Entity review through Medicare's appeals process.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Fintepla. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals tailored to each payer's requirements. We help patients, clinicians, and specialty pharmacies navigate prior authorization challenges with targeted documentation that addresses payer-specific policies and procedural requirements.

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider. Insurance policies and procedures change frequently; always verify current requirements with Humana and consult official sources. For personalized assistance with your specific situation, contact the resources listed above or consult with a qualified healthcare advocate.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.