By Counterforce Health Team in Firdapse (amifampridine) —

How to Get Firdapse (Amifampridine) Covered by Aetna CVS Health in Florida: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Firdapse Covered by Aetna CVS Health in Florida

Fastest path to approval: Submit prior authorization through Aetna's provider portal with neurologist documentation, EMG showing ≥60% increment, VGCC antibody results (if positive), and ICD-10 code G70.80. If denied, file internal appeal within 180 days, then external review within 120 days through Florida's Department of Financial Services.

First step today: Contact your neurologist to gather diagnostic documentation (EMG, antibodies) and have them submit the PA request via Aetna's provider portal or call 1-888-632-3862.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Setup
  8. After Submission: What to Expect
  9. Common Denial Reasons & How to Fix Them
  10. Appeals Process in Florida
  11. Costs & Financial Assistance
  12. Frequently Asked Questions

Who Should Use This Guide

This guide helps Florida residents with Aetna CVS Health insurance get Firdapse (amifampridine) covered for Lambert-Eaton myasthenic syndrome (LEMS). You'll need this if:

  • Your doctor prescribed Firdapse for confirmed LEMS
  • You received a prior authorization denial
  • You're preparing to submit an initial PA request
  • You need to appeal a coverage decision

Expected outcome: With proper documentation, many LEMS patients get approved. If initially denied, appeals have overturn rates of 15-40% nationally when supported by strong clinical evidence.

Member & Plan Basics

Coverage Requirements

  • Active Aetna CVS Health coverage (commercial, Medicare Advantage, or Medicaid)
  • Specialty drug benefits included in your plan
  • Prior authorization required for all Firdapse requests

Plan Type Considerations

  • Commercial plans: 180-day appeal window
  • Medicare Advantage: 65-day appeal window
  • Medicaid: 60-day appeal window
Tip: Check your member ID card or call member services at 1-844-528-5815 to confirm your plan type and specialty pharmacy benefits.

Clinical Criteria for Approval

Aetna requires all of the following for Firdapse approval:

Diagnosis Requirements

  • Confirmed LEMS diagnosis with ICD-10 code G70.80
  • Neurologist or neuromuscular specialist prescription/consultation
  • Objective diagnostic evidence:
    • EMG showing ≥60% increment after brief exercise or high-frequency stimulation, OR
    • Positive anti-P/Q-type VGCC antibodies (present in 85-95% of cases)

Patient Criteria

  • Age 6 years or older (FDA minimum)
  • No history of seizures (contraindication)
  • Maximum dose: 100 mg/day per updated FDA labeling

Step Therapy

If required, document failure/intolerance of:

  • Pyridostigmine
  • IVIG or plasmapheresis
  • Immunosuppressive therapy (if applicable)

Coding Requirements

Code Type Code Description
ICD-10 G70.80 Lambert-Eaton syndrome, unspecified
HCPCS J8499 Prescription drug, oral, non-chemotherapeutic, NOS
NDC 64894-701-01 Firdapse 10 mg tablets (bottle of 100)
Note: Always verify current NDC numbers with dispensed product packaging.

Documentation Packet

Required Clinical Documentation

  1. Neurologist's letter of medical necessity including:
    • LEMS diagnosis confirmation
    • Prior therapy failures/contraindications
    • Dosing rationale
    • Treatment goals
  2. Diagnostic test results:
    • EMG/NCS report showing characteristic LEMS findings
    • VGCC antibody results (if tested)
    • Clinical examination notes
  3. Insurance verification:
    • Copy of insurance card (front and back)
    • Patient demographics
    • Prescriber NPI, DEA, and state license numbers

Medical Necessity Letter Components

Your neurologist should address:

  • Clinical presentation: Proximal muscle weakness, areflexia, autonomic symptoms
  • Differential diagnosis: How myasthenia gravis and other conditions were ruled out
  • FDA indication: Firdapse is the only FDA-approved amifampridine for LEMS
  • Seizure screening: Confirmation of no seizure history
  • Monitoring plan: Regular neurological assessments

Submission Process

Step-by-Step Submission

  1. Gather documentation (neurologist, patient, clinic staff)
  2. Complete PA request via Aetna provider portal or call 1-888-632-3862
  3. Submit within 24-48 hours of prescription writing
  4. Follow up in 3-5 business days for status update

Common Submission Errors to Avoid

  • Incomplete diagnostic documentation
  • Missing neurologist attestation
  • Wrong ICD-10 code (use G70.80, not G73.1)
  • Exceeding FDA dose limits
  • Missing seizure risk assessment

Specialty Pharmacy Setup

Firdapse requires specialty pharmacy dispensing through two programs:

Catalyst Pathways Program

  • Manufacturer support program for LEMS patients
  • Enrollment required for insurance coordination
  • Contact: 1-833-422-8259
  • Fax enrollment form: 1-833-422-8260

CVS Specialty Pharmacy

  • Aetna's preferred specialty pharmacy
  • Enrollment form required with prescriber and patient signatures
  • Coordinates with Catalyst Pathways for seamless care
  • Find forms: CVS Specialty enrollment page
Important: Both enrollments may be needed to ensure coverage and avoid therapy delays.

After Submission: What to Expect

Timeline Expectations

  • Standard PA decision: 30-45 days
  • Expedited review: 72 hours (if urgent)
  • Approval duration: Initial 3 months, then 12-month renewals

Status Tracking

  • Confirmation number: Record from initial submission
  • Check status: Aetna provider portal or member services
  • Follow-up schedule: Every 5-7 business days until decision

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Lack of LEMS confirmation Submit EMG report showing increment ≥60% and/or VGCC antibody results
Non-specialist prescriber Obtain neurologist consultation and prescription
Missing seizure screening Provide documentation of no seizure history
Step therapy required Document failure/intolerance of pyridostigmine or other required therapies
Exceeds dose limits Justify dosing per FDA labeling or reduce to maximum 100 mg/day
Age restriction Confirm patient is ≥6 years old per FDA indication

Appeals Process in Florida

Internal Appeal (First Level)

  • Timeline: File within 180 days of denial (commercial), 65 days (Medicare), 60 days (Medicaid)
  • Decision time: 30 days standard, 72 hours expedited
  • How to file: Aetna provider portal, phone, mail, or fax
  • Required: Original denial letter, additional clinical documentation, medical necessity letter

External Review (Independent Review)

  • When to use: After unsuccessful internal appeal
  • Timeline: Request within 120 days of final internal denial
  • Process: Contact Florida Department of Financial Services
  • Cost: Free to consumer
  • Decision: Binding on insurer if overturned

Expedited Appeals

Request expedited review if:

  • Waiting could seriously harm your health
  • You're currently taking Firdapse and coverage was terminated
  • Your doctor certifies urgency

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Our platform identifies the specific denial basis and drafts point-by-point rebuttals aligned with each plan's own coverage rules.

Costs & Financial Assistance

Without Insurance Coverage

  • Retail cost: Approximately $28,800 per month (varies by dose)
  • Annual cost: Historic reports of ~$375,000/year

Financial Assistance Options

  1. Catalyst Pathways Patient Assistance: Income-based free drug program
  2. Copay assistance: May reduce out-of-pocket costs for commercial insurance
  3. Foundation grants: Organizations supporting rare disease patients
  4. State programs: Florida may have additional assistance programs

Contact Catalyst Pathways at 1-833-422-8259 for current assistance program details.

Frequently Asked Questions

Q: How long does Aetna prior authorization take in Florida? A: Standard decisions take 30-45 days. Expedited reviews (for urgent cases) are completed within 72 hours.

Q: What if Firdapse is non-formulary on my plan? A: You can request a formulary exception with medical necessity documentation. Appeals often succeed when FDA indication and clinical evidence are provided.

Q: Can I get an expedited appeal if I'm already taking Firdapse? A: Yes, if your doctor certifies that stopping treatment could harm your health, you can request expedited internal and external review simultaneously.

Q: Do I need to try other treatments first? A: This depends on your specific plan's step therapy requirements. Many plans require documented failure of pyridostigmine or contraindication to its use.

Q: What happens if my appeal is denied? A: You can request external review through Florida's Department of Financial Services within 120 days. This independent medical review is binding on the insurer.

Q: Does my neurologist need to be in-network? A: For prescription writing, no. However, in-network specialists may have easier access to Aetna's systems for PA submission and peer-to-peer reviews.

From our advocates: We've seen LEMS patients succeed by ensuring their neurologist clearly documents the EMG increment findings and emphasizes that Firdapse is the only FDA-approved treatment for their condition. When appeals include both objective test results and strong medical necessity letters, approval rates improve significantly.

Whether you're navigating your first prior authorization or appealing a denial, having the right documentation and understanding Florida's appeal rights puts you in the strongest position for coverage success. Counterforce Health's platform can help streamline this process by creating targeted appeals that address your specific denial reasons with evidence-backed responses.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual circumstances, plan details, and medical necessity. Always consult with your healthcare provider and insurance company for specific guidance. For assistance with insurance complaints in Florida, contact the Department of Financial Services at 1-877-693-5236.

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