By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (Fenfluramine) Covered by Humana in Ohio: Prior Authorization, Appeals & Timelines

Quick Answer: Getting Fintepla Covered by Humana in Ohio

Fintepla (fenfluramine) requires prior authorization from Humana with specific documentation: confirmed Dravet syndrome or Lennox-Gastaut syndrome diagnosis, evidence of failed trials with at least two prior anti-seizure medications, REMS program enrollment, and baseline echocardiogram results. Submit through your prescriber via Humana's provider portal or CenterWell Specialty Pharmacy at 1-800-486-2668. If denied, you have 65 days to appeal with Ohio's external review available within 180 days of final denial through the Ohio Department of Insurance.

First step today: Contact your neurologist to initiate REMS enrollment and gather documentation of prior seizure medication trials.

Table of Contents

  1. Humana Plan Types & Coverage Implications
  2. Fintepla Formulary Status & Requirements
  3. Prior Authorization & Utilization Controls
  4. CenterWell Specialty Pharmacy Process
  5. Cost-Share & Financial Assistance
  6. Submission Process & Forms
  7. Common Approval Strategies
  8. Appeals Process for Ohio Residents
  9. Verification & Resources
  10. FAQ

Humana Plan Types & Coverage Implications

Humana offers several plan types in Ohio, each with different coverage rules for Fintepla:

Medicare Advantage Plans: Most common Humana coverage in Ohio. These plans follow Medicare Part D rules for prescription coverage, with 65-day appeal timelines and standardized prior authorization processes.

Commercial Plans: Employer-sponsored coverage with varying formularies. Step therapy requirements may differ from Medicare plans.

Medicaid Plans: Limited Humana Medicaid presence in Ohio; most Medicaid members use other carriers like CareSource or Molina.

Note: Self-funded employer plans follow federal ERISA rules rather than Ohio state insurance regulations for appeals.

Fintepla Formulary Status & Requirements

Fintepla is included in Humana's pharmacy coverage with specific restrictions:

Coverage Requirements

Requirement Details Source
Prior Authorization Required for all plans Humana Formulary
REMS Enrollment Mandatory for prescriber and patient FDA REMS Program
Diagnosis Dravet syndrome or Lennox-Gastaut syndrome Humana Policy
Age Requirement 2 years and older FDA Label
Baseline Testing Echocardiogram required REMS Requirements

Alternative Medications

If Fintepla is denied, Humana typically covers these alternatives for Dravet syndrome and Lennox-Gastaut syndrome:

  • Clobazam (Onfi)
  • Cannabidiol (Epidiolex)
  • Valproate
  • Stiripentol (Diacomit)
  • Rufinamide (Banzel)
  • Lamotrigine

Prior Authorization & Utilization Controls

Required Documentation

Your neurologist must submit these documents for prior authorization approval:

  1. Diagnosis Confirmation: Medical records confirming Dravet syndrome or Lennox-Gastaut syndrome diagnosis
  2. Treatment History: Documentation of at least two failed anti-seizure medication trials
  3. REMS Enrollment: Completed prescriber and patient enrollment forms
  4. Baseline Echocardiogram: Results showing no valvular heart disease
  5. Clinical Justification: Letter explaining medical necessity

Clinician Corner: Medical Necessity Letter Checklist

✅ Problem Statement: Current seizure frequency and impact on daily functioning
✅ Prior Treatments: Specific medications tried, doses, duration, and reasons for discontinuation
✅ Clinical Rationale: Why Fintepla is appropriate based on FDA-approved indications
✅ Monitoring Plan: Cardiac monitoring schedule per REMS requirements
✅ Dosing Justification: Weight-based dosing calculation and titration plan

CenterWell Specialty Pharmacy Process

CenterWell Specialty Pharmacy is Humana's preferred specialty pharmacy for Fintepla in Ohio.

Getting Started

Contact Information:

  • Phone: 1-800-486-2668 (TTY: 711)
  • Fax for prescriptions: 1-877-405-7940
  • Hours: Monday–Friday 8 AM–11 PM, Saturday 8 AM–6:30 PM ET

Setup Process

  1. Prescription Transfer: Your prescriber faxes the prescription to CenterWell
  2. Prior Authorization: CenterWell coordinates PA submission with your doctor
  3. REMS Enrollment: Pharmacy assists with REMS program enrollment
  4. Financial Assistance: Specialists help apply for copay assistance programs
  5. Delivery Coordination: Medication shipped to your home with clinical support

Cost-Share & Financial Assistance

Typical Costs

Fintepla's cash price is approximately $1,595 for a 30-mL bottle, with monthly costs varying by prescribed dose. Your Humana plan's cost-sharing depends on:

  • Deductible status (if applicable)
  • Formulary tier placement
  • Specialty pharmacy copay structure

Financial Assistance Options

UCB ONWARD Copay Assistance Program:

  • Reduces copays to $0-$25 for commercial insurance
  • Available through Fintepla ONWARD Support
  • CenterWell can help with enrollment

Other Resources:

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • HealthWell Foundation

Submission Process & Forms

For Prescribers

Submit prior authorization requests through:

Required Forms

While specific form names weren't available in research, typical submissions include:

  • Prior authorization request form
  • Clinical documentation
  • REMS enrollment confirmation
  • Echocardiogram results
Tip: Contact CenterWell Specialty Pharmacy to coordinate submission—they often handle PA paperwork directly with prescribers.

Common Approval Strategies

Step-by-Step: Fastest Path to Approval

  1. REMS Enrollment (Patient & Prescriber): Complete enrollment at FinteplaREMS.com before PA submission
  2. Baseline Echo: Schedule and complete echocardiogram showing no valvular disease
  3. Document Treatment History: Gather records of at least 2 failed anti-seizure medications
  4. Submit Comprehensive PA: Include all required documentation in initial submission
  5. Follow Up: Contact CenterWell within 3 business days to confirm receipt
  6. Track Status: Monitor through Humana provider portal or member services
  7. Appeal if Denied: Submit appeal within 65 days with additional clinical support

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Insufficient treatment history Document specific medication trials Pharmacy records, clinic notes
Missing REMS enrollment Complete enrollment before resubmission REMS confirmation emails
Inadequate diagnosis documentation Provide genetic testing or clinical criteria EEG results, genetic panel
Cardiac concerns Submit current echo results Cardiology consultation if needed

Appeals Process for Ohio Residents

Internal Appeals (Humana)

Timeline: 65 days from denial to file appeal

Standard Review: 7 calendar days for decision
Expedited Review: 72 hours for urgent cases

How to Appeal:

  • Online: Humana member portal
  • Phone: 800-867-6601
  • Mail/Fax: Complete redetermination form

External Review (Ohio)

If Humana upholds the denial, Ohio residents can request external review through the Ohio Department of Insurance:

Timeline: 180 days from final Humana denial
Process: Independent medical review by certified experts
Contact: 1-800-686-1526 (ODI Consumer Services)

From our advocates: We've seen families succeed by submitting comprehensive appeals that include peer-reviewed studies supporting Fintepla's efficacy in treatment-resistant epilepsy, along with detailed seizure logs showing inadequate control with standard therapies. The key is demonstrating that Fintepla isn't just preferred—it's medically necessary based on the patient's specific clinical history.

When to Escalate

Contact Ohio Department of Insurance if:

  • Humana delays processing beyond required timeframes
  • You need help understanding your appeal rights
  • The insurer incorrectly claims your case isn't eligible for external review

Verification & Resources

Direct Policy Verification

Ohio-Specific Resources

  • Ohio Department of Insurance: 1-800-686-1526
  • OSHIIP (Ohio Senior Health Insurance Information Program): For Medicare-related appeals
  • UHCAN Ohio: Nonprofit advocacy for health insurance appeals

Professional Support

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, including the specific clinical evidence and procedural documentation that plans like Humana expect for specialty medications like Fintepla.

FAQ

How long does Humana prior authorization take for Fintepla in Ohio?
Standard PA decisions are typically made within 15 business days, though CenterWell Specialty Pharmacy can expedite urgent requests.

What if Fintepla is non-formulary on my Humana plan?
You can request a formulary exception with medical necessity documentation. The same clinical criteria apply.

Can I request an expedited appeal if my child's seizures are worsening?
Yes, expedited appeals are available when delays could seriously harm health. Call 800-867-6601 to request expedited review.

Does step therapy apply if we've tried medications outside Ohio?
Medical records from any state are acceptable for documenting prior medication failures.

What happens if the external review in Ohio is denied?
You retain rights to seek other remedies, including regulatory complaints or legal action, though external review is typically the final administrative step.

How do I get help with the REMS enrollment process?
CenterWell Specialty Pharmacy provides step-by-step guidance, or contact the Fintepla REMS program directly.

Are there any Ohio-specific protections for step therapy?
Ohio has step therapy exception provisions under Section 3901.832 that may apply in certain circumstances.

What if my employer plan is self-funded?
Self-funded plans follow federal ERISA rules rather than Ohio state regulations, but many voluntarily use similar external review processes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Consult your healthcare provider for medical guidance and contact Humana directly for plan-specific coverage information. For assistance with appeals in Ohio, contact the Ohio Department of Insurance at 1-800-686-1526.

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