By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (fenfluramine) Covered by Humana in Virginia: Prior Authorization Forms, Appeals, and Step-by-Step Guide

Quick Answer: Getting Fintepla Covered by Humana in Virginia

To get Fintepla (fenfluramine) covered by Humana in Virginia, you need prior authorization with specific documentation: confirmed Dravet syndrome or Lennox-Gastaut syndrome diagnosis, evidence of at least two failed antiseizure medications, baseline echocardiogram results, and enrollment in the FDA REMS program. Submit through CoverMyMeds portal or fax to 1-888-447-3430. If denied, you have 65 days to appeal internally, then 120 days for external review through Virginia's State Corporation Commission. Start today: Contact your neurologist to gather required documentation and initiate REMS enrollment.

Table of Contents

Verify Your Plan Coverage

Before starting the prior authorization process, confirm your specific Humana plan details. Fintepla requires prior authorization across all Humana products in Virginia, including Medicare Advantage, Medicaid (Healthy Horizons), and commercial plans.

What to check:

  • Your member ID and plan type
  • Current formulary status (typically Tier 4 or 5 specialty)
  • Network specialty pharmacy requirements
  • Your plan's specific prior authorization forms
Tip: Call Humana Member Services at the number on your insurance card to confirm your plan covers specialty medications and verify current prior authorization requirements.

Required Forms and Documentation

Core Prior Authorization Requirements

Humana requires comprehensive documentation for Fintepla approval:

Requirement Details Where to Get It
Diagnosis Confirmation Dravet syndrome or Lennox-Gastaut syndrome with ICD-10 codes Neurologist/epileptologist
Treatment History Documentation of at least 2 failed antiseizure medications Medical records from all providers
REMS Enrollment Both patient and prescriber must be enrolled Fintepla REMS website
Baseline Echocardiogram Required before starting treatment Cardiology or ordering physician
Specialist Consultation Prescribed by or in consultation with neurologist Neurology clinic

Medical Necessity Documentation

Your healthcare provider must submit a detailed medical necessity letter including:

  • Specific seizure frequency and type
  • Previous antiseizure medications tried, doses, duration, and reasons for discontinuation
  • Current seizure impact on daily functioning
  • Clinical rationale for Fintepla specifically
  • Treatment goals and expected outcomes

Submission Portals and Process

Primary Submission Methods

Electronic Submission (Preferred):

Fax Submission:

  • Medication Intake Team: 1-888-447-3430
  • Include completed prior authorization form and all supporting documentation

Required Documentation Checklist

Before submitting, ensure you have:

  • Completed Humana prior authorization form
  • Medical necessity letter from prescriber
  • Diagnosis confirmation with ICD-10 codes
  • Treatment history documentation
  • REMS enrollment confirmation
  • Baseline echocardiogram report
  • Specialist consultation notes

REMS Program Requirements

The FDA requires strict monitoring for Fintepla due to cardiovascular risks. Both patients and prescribers must enroll in the REMS program before treatment can begin.

Echocardiography Schedule

Timing Requirement Documentation Needed
Before Treatment Baseline echocardiogram Full report showing no valvular disease
Every 6 Months Ongoing monitoring Updated echo reports
3-6 Months After Stopping Final assessment Post-treatment echo

REMS Enrollment Steps

  1. Prescriber Enrollment: Complete training and register at Fintepla REMS
  2. Patient Enrollment: Submit patient enrollment form
  3. Pharmacy Certification: Ensure dispensing pharmacy is REMS-certified
  4. Ongoing Compliance: Maintain current enrollment status
Note: REMS enrollment confirmation must be included with every prior authorization submission to Humana.

Step-by-Step: Fastest Path to Approval

Step 1: Gather Clinical Documentation (Patient + Provider)

  • Schedule appointment with neurologist or epileptologist
  • Collect complete seizure history and medication trial records
  • Obtain baseline echocardiogram if not already done
  • Timeline: 1-2 weeks

Step 2: Complete REMS Enrollment (Provider + Patient)

  • Prescriber completes REMS training and enrollment
  • Submit patient enrollment form with required signatures
  • Timeline: 3-5 business days for approval

Step 3: Submit Prior Authorization (Provider)

  • Complete Humana's prior authorization form
  • Submit via CoverMyMeds or fax to 1-888-447-3430
  • Include all required documentation
  • Timeline: Same day submission possible

Step 4: Follow Up and Track Status (Patient + Provider)

  • Monitor submission status through portal or by calling Humana
  • Respond promptly to any requests for additional information
  • Timeline: 7-day standard review period

Step 5: If Approved, Coordinate Specialty Pharmacy (Patient)

  • Transfer prescription to CenterWell Specialty Pharmacy
  • Arrange home delivery and clinical support
  • Timeline: 1-3 business days for first shipment

Common Denial Reasons & Solutions

Denial Reason How to Address Required Documentation
Missing REMS Documentation Submit enrollment confirmation REMS portal screenshots or certificates
Insufficient Treatment History Provide detailed medication trial records Pharmacy records, physician notes
Missing Echocardiogram Submit baseline cardiac assessment Complete echo report with interpretation
Diagnosis Not Supported Provide specialist confirmation Neurology consultation with EEG results
Step Therapy Not Met Document failed trials of preferred agents Treatment timelines and adverse effects

Appeals Process for Virginia Residents

If your initial prior authorization is denied, Virginia residents have robust appeal rights through both Humana's internal process and state external review.

Internal Appeals with Humana

Timeline: 65 days from denial notice (Medicare) or 60 days (Medicaid)

Submission Methods:

  • Online through Humana member portal
  • Mail to address on denial letter
  • Fax to appeals department
  • Phone request followed by written confirmation

Required Elements:

  • Copy of original denial letter
  • Additional clinical documentation
  • Updated medical necessity letter addressing denial reasons

Virginia External Review Process

If Humana's internal appeal is unsuccessful, Virginia law provides for independent external review through the State Corporation Commission.

Key Details:

  • Deadline: 120 days from final Humana denial
  • Form Required: Form 216-A (External Review Request)
  • Filing Options: Mail, fax (804-371-9915, or email [email protected]
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to patients

Contact Information: State Corporation Commission
Bureau of Insurance – External Review
P.O. Box 1157
Richmond, VA 23218
Phone: 1-877-310-6560

Important: The external review decision is binding on Humana and has successfully overturned many specialty drug denials in Virginia.

Specialty Pharmacy Requirements

Humana requires Fintepla to be dispensed through their contracted specialty pharmacy network, primarily CenterWell Specialty Pharmacy.

Transfer Instructions

  1. Contact CenterWell: 800-486-2668 (Monday-Friday 8 AM-11 PM, Saturday 8 AM-6:30 PM ET)
  2. Provide Information: Humana member ID, prescriber details, prior authorization number
  3. Coordinate Delivery: Arrange home shipping and clinical support services
  4. Fax Prescriptions: Providers can fax to 1-877-405-7940

Clinical Support Services

CenterWell provides:

  • Medication adherence monitoring
  • Side effect management consultation
  • Insurance navigation assistance
  • Coordination with REMS requirements

Cost Support and Patient Assistance

Manufacturer Support Programs

UCB offers patient assistance through the ONWARD Patient Support Program:

  • Prior authorization support
  • Insurance navigation
  • Financial assistance for eligible patients
  • REMS enrollment guidance

Additional Resources

  • UCB Patient Assistance Program: Income-based medication assistance
  • State Pharmacy Assistance: Virginia may have additional programs for qualifying residents
  • Foundation Grants: Epilepsy Foundation and similar organizations may provide support
Tip: Contact the ONWARD program at finteplahcp.com early in the process for comprehensive support.

When to Contact Virginia Regulators

Contact the Virginia State Corporation Commission Bureau of Insurance if:

  • Humana fails to respond to appeals within required timeframes
  • You believe the denial violates Virginia insurance law
  • You need guidance on the external review process
  • You experience procedural issues with your appeal

Consumer Services: 1-877-310-6560

The Bureau can provide guidance, investigate complaints, and ensure compliance with Virginia insurance regulations.

Getting specialized medication approved can feel overwhelming, but Virginia residents have strong protections and multiple pathways to coverage. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, payer-specific documentation that addresses denial reasons point-by-point. Their platform streamlines the complex process of gathering clinical evidence, meeting procedural requirements, and crafting compelling medical necessity arguments that align with each payer's specific criteria and workflows.

FAQ

How long does Humana's prior authorization process take for Fintepla? Standard review takes up to 7 calendar days. Expedited review (if medically urgent) can be completed in 24-72 hours with provider certification of medical urgency.

What if Fintepla isn't on Humana's formulary? You can request a formulary exception along with your prior authorization. This requires additional documentation showing medical necessity for Fintepla specifically versus formulary alternatives.

Can I get an expedited appeal if my child's seizures worsen? Yes. If your doctor certifies that delay could seriously harm your health, Virginia allows expedited external review within 72 hours, and Humana must provide expedited internal review within 24-72 hours.

Does treatment history from outside Virginia count for step therapy? Yes. Document all previous treatments regardless of where they were received. Ensure your Virginia healthcare provider has complete records from previous states or providers.

What happens if I start Fintepla before getting approval? If you fill Fintepla before prior authorization approval, you'll be responsible for the full cost (approximately $1,595 for a 30-mL bottle). Always wait for approval confirmation before dispensing.

Can I appeal if Humana requires me to try other medications first? Yes. You can request a step therapy exception if your doctor believes other medications would be ineffective, harmful, or inappropriate for your specific condition.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For personalized assistance with Virginia insurance matters, contact the Virginia State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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