By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (Fenfluramine) Covered by Humana in Washington: Complete Prior Authorization Guide with Forms and Appeals

Answer Box: Getting Fintepla Covered by Humana in Washington

Fintepla (fenfluramine) requires prior authorization from Humana Medicare Advantage plans for Dravet syndrome or Lennox-Gastaut syndrome. Submit via CoverMyMeds portal with REMS enrollment proof, baseline echocardiogram, and medical necessity letter. Standard approval takes 7 days; request expedited review (72 hours) for urgent cases. If denied, file internal appeal within 65 days, then request Washington state external review through the Office of the Insurance Commissioner within 180 days.

First step today: Verify your Humana plan covers specialty drugs and gather REMS documentation from FinteplaREMS.com.

Table of Contents

  1. Verify Your Humana Plan Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. REMS Program Requirements
  5. Appeals Process for Humana in Washington
  6. Specialty Pharmacy Setup
  7. Support Lines and Contacts
  8. Washington State External Review
  9. Common Denial Reasons and Solutions
  10. FAQ

Verify Your Humana Plan Coverage

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

Coverage Check Steps:

  1. Log into your Humana member portal or call the number on your ID card
  2. Search the Medicare Drug List for Fintepla
  3. Note the formulary tier and any restrictions (step therapy, quantity limits)
  4. Verify your plan includes specialty pharmacy benefits
Tip: Humana's PA denial rate for Medicare Advantage is approximately 3.5% (2023)—among the lowest of major insurers—but denials often stem from incomplete documentation rather than medical necessity.

Prior Authorization Forms and Requirements

Required Documentation Checklist

Patient Information:

  • Humana member ID and plan details
  • Patient age and weight (for dosing calculations)
  • Diagnosis confirmation: Dravet syndrome (ICD-10: G40.A1) or Lennox-Gastaut syndrome (ICD-10: G40.81)

Clinical Documentation:

  • Neurologist's medical necessity letter
  • Prior antiseizure medication trials (≥2 required): names, doses, durations, reasons for discontinuation
  • Current seizure frequency logs
  • Baseline echocardiogram results

REMS Requirements:

  • Prescriber REMS enrollment confirmation
  • Patient REMS enrollment form
  • Echocardiogram showing no moderate/severe valve regurgitation and pulmonary artery systolic pressure ≤35 mmHg

Submission Portals and Methods

Electronic Submission (Fastest Method)

CoverMyMeds Portal:

  • Access: account.covermymeds.com
  • Benefit: Real-time determinations, up to 3x faster than phone/fax
  • Process: Select Humana-specific ePA form and upload all required documents

Alternative Submission Methods

Method Contact Information Processing Time
Online (Part D) Humana provider portal 7 days standard
Fax 877-486-2621 (mainland)
855-681-8650 (Puerto Rico)		 7-10 days
Phone 800-555-2546
Mon-Fri 8am-8pm local time		 Immediate review
Note: Electronic submissions via CoverMyMeds can accelerate therapy starts by up to 13 days compared to traditional methods.

REMS Program Requirements

Fintepla requires enrollment in a Risk Evaluation and Mitigation Strategy (REMS) program due to cardiovascular risks.

Prescriber Requirements

  1. Complete Prescriber Enrollment Form
  2. Counsel patients on valvular heart disease and pulmonary hypertension risks
  3. Order baseline echocardiogram and review results
  4. Submit treatment authorization via REMS portal

Patient Requirements

  1. Complete Patient Enrollment Form
  2. Undergo baseline echocardiogram
  3. Schedule follow-up echos every 6 months during treatment
  4. Receive medication only from certified pharmacies

REMS Contact Information

Appeals Process for Humana in Washington

Internal Appeals Timeline

Appeal Level Deadline to File Decision Timeline How to Submit
Level 1 65 days from denial 7 days standard
72 hours expedited		 Humana member portal or fax
Level 2 60 days from Level 1 denial 30 days standard
72 hours expedited		 Independent Review Entity

Required Appeal Documents

  • Copy of original denial letter
  • Updated medical necessity letter from prescriber
  • Any new clinical evidence or test results
  • Patient impact statement (optional but helpful)

Expedited Appeal Criteria: Request expedited review if delay could seriously jeopardize patient's health or ability to regain maximum function.

Specialty Pharmacy Setup

Humana partners with CenterWell Specialty Pharmacy for complex medications like Fintepla.

Setup Process

  1. Provider: E-prescribe to CenterWell or call 1-800-CENTERWELL
  2. Patient: Complete enrollment forms and insurance verification
  3. Coordination: CenterWell handles prior authorization submission via CoverMyMeds
  4. Delivery: Home delivery with clinical support and adherence monitoring
Advantage: CenterWell Specialty Pharmacy covers 96% of specialty drugs and integrates directly with Humana's approval systems.

Support Lines and Contacts

Humana Member Services

  • Primary: Number on back of member ID card
  • General: 866-427-7478
  • Backup: 800-457-4708 (TTY: 711)
  • Hours: Monday-Friday, 8am-8pm local time

Provider Support

  • Clinical Intake: 800-523-0023 (24/7)
  • Prior Authorization: 800-555-2546
  • Case Management: 866-868-5092 (for eligible dual-eligible members)

When to Call

  • Check PA status
  • Request expedited review
  • Appeal assistance
  • Specialty pharmacy coordination

Washington State External Review

If Humana denies your internal appeals, Washington residents can request an independent external review through the Office of the Insurance Commissioner (OIC).

External Review Process

  1. Eligibility: Available after exhausting internal appeals
  2. Deadline: 180 days from final internal denial
  3. Cost: Free to consumers
  4. Decision: Binding on insurer if approved

How to Request External Review

Contact Washington OIC:

Required Information:

  • Policy and claim numbers
  • All denial letters
  • Medical records supporting necessity
  • Physician statement on urgency

Timeline for External Review

  • Standard: 30-45 days
  • Expedited: 72 hours (if health at risk)
  • Outcome: If approved, Humana must provide coverage

Counterforce Health specializes in transforming insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies specific denial reasons and crafts point-by-point responses aligned with each plan's requirements, significantly improving approval rates for complex medications like Fintepla.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing REMS enrollment Complete REMS process Prescriber and patient enrollment confirmations
Insufficient diagnosis support Provide detailed records Neurologist notes, genetic testing, seizure logs
Step therapy not met Document prior failures Medication trial history with dates, doses, outcomes
Drug interactions Clinical justification Risk-benefit analysis, monitoring plan
Non-formulary status Request exception Medical necessity letter, alternative failures

Clinician Corner: Medical Necessity Letter Essentials

Key Components:

  1. Patient diagnosis with ICD-10 codes and severity
  2. Prior treatment history including specific medications, doses, durations, and reasons for discontinuation
  3. Clinical rationale for Fintepla based on FDA labeling and treatment guidelines
  4. Monitoring plan including REMS compliance and follow-up schedule
  5. Expected outcomes and goals of therapy

Supporting Evidence:

  • FDA prescribing information
  • Clinical trial data showing efficacy in refractory epilepsy
  • Professional society guidelines for Dravet or LGS treatment

FAQ

How long does Humana prior authorization take for Fintepla in Washington? Standard review takes 7 days; expedited review for urgent cases takes 72 hours. Electronic submissions via CoverMyMeds are typically fastest.

What if Fintepla is non-formulary on my Humana plan? Request a formulary exception with a medical necessity letter explaining why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal if Humana denies coverage? Yes, if delays could seriously jeopardize your health. Submit expedited appeal request with physician statement documenting urgency.

Does Washington state law provide additional appeal rights? Yes, Washington offers independent external review through the Office of the Insurance Commissioner after exhausting internal appeals, with decisions binding on insurers.

What REMS requirements must be completed before approval? Both prescriber and patient must enroll in the REMS program, and baseline echocardiogram must show no significant valve disease or pulmonary hypertension.

How much does Fintepla cost without insurance? Typical cash price is approximately $1,595 for a 30-mL bottle, though total monthly costs vary by prescribed dose.

Can specialty pharmacies help with the prior authorization process? Yes, CenterWell Specialty Pharmacy can coordinate with Humana and submit prior authorization requests on your behalf.

What should I do if my appeal is denied? File for external review with Washington's Office of the Insurance Commissioner within 180 days. The independent review organization's decision is binding on Humana.

From our advocates: We've seen families successfully overturn Fintepla denials by ensuring REMS documentation is complete before submission and including detailed seizure logs showing inadequate control with prior medications. The key is presenting a comprehensive clinical picture that clearly demonstrates medical necessity according to the plan's own criteria.

When facing insurance denials for critical medications like Fintepla, Counterforce Health helps patients and clinicians navigate complex prior authorization requirements and appeals processes, turning denials into approvals through strategic, evidence-based advocacy.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific guidance regarding your coverage and treatment options. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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