By Counterforce Health Team in Fintepla (fenfluramine) —

Lowering Out-of-Pocket Costs for Fintepla with UnitedHealthcare in Pennsylvania: Complete Copay, Tiering & Financial Assistance Guide

Answer Box: Getting Fintepla Covered by UnitedHealthcare in Pennsylvania

Fintepla (fenfluramine) requires prior authorization from UnitedHealthcare and is placed on Specialty Tier 5 with high out-of-pocket costs. To minimize expenses: 1) Apply for UCB's ONWARD Copay Assistance Program (can reduce copays to $0-$25 for commercial insurance), 2) Request a tier exception if denied, and 3) Use Pennsylvania's new external review program if appeals are needed. Start by confirming REMS enrollment and gathering clinical documentation for your prescriber to submit the PA request through UnitedHealthcare's provider portal.

Table of Contents

What Drives Fintepla Costs with UnitedHealthcare

Benefit Design Basics

UnitedHealthcare places Fintepla on Specialty Tier 5 in their 2025 formularies, meaning higher cost-sharing than standard medications. Specialty tiers typically require:

  • Coinsurance (percentage of drug cost) rather than fixed copays
  • Prior authorization for all prescriptions
  • Specialty pharmacy dispensing requirements
  • Step therapy protocols requiring trial of preferred alternatives first

Understanding Your Cost Structure

Cost Component What It Means Typical Range
Specialty Coinsurance Your percentage of Fintepla's cost after deductible 20-50% of ~$1,595/month
Deductible Amount you pay before insurance kicks in $500-$3,000+ annually
Out-of-pocket maximum Annual limit on your total costs $2,000-$8,000+
Note: Self-funded employer plans may have different cost structures than standard UnitedHealthcare policies.

Investigating Your Benefits

Key Questions for UnitedHealthcare

Call the member services number on your insurance card and ask:

  1. "What's my specialty drug coinsurance percentage?"
  2. "Does my deductible apply to specialty medications?"
  3. "What's my annual out-of-pocket maximum?"
  4. "Which specialty pharmacy must I use?"
  5. "Are there any quantity limits on Fintepla?"

Information to Document

Keep a record of:

  • Policy/Group number and effective dates
  • Specialty pharmacy network (OptumRx vs. others)
  • Prior authorization status and approval timeline
  • Step therapy requirements and completed trials
  • Appeal deadlines and submission methods

Manufacturer and Foundation Assistance

UCB ONWARD Copay Assistance Program

The ONWARD Copay Assistance Program can reduce out-of-pocket costs significantly:

  • Eligible patients with commercial insurance may pay $0-$25 in copays
  • Not valid for government insurance (Medicare, Medicaid, TRICARE)
  • Enrollment available through UCB Patient Support Services at 1-833-463-7547

Additional UCB Support

  • ONWARD Echocardiogram Copay Support: Assists with cardiac monitoring costs required by the REMS program
  • UCB Patient Assistance Program: For uninsured or underinsured patients (income limits apply)

Foundation Grants

While the LGS Foundation's Elevate Program is currently closed, other options include:

  • Epilepsy Foundation local chapters in Pennsylvania
  • RxAssist.org database of patient assistance programs
  • NeedyMeds.org comprehensive medication assistance directory
From our advocates: A family in Pennsylvania successfully combined the UCB copay card with their employer's health savings account to cover the remaining specialty pharmacy dispensing fees, reducing their monthly Fintepla costs from over $400 to under $50. They emphasized the importance of applying for manufacturer assistance before the first prescription fill.

Requesting Tier Exceptions

When to Request an Exception

Consider a tier exception if:

  • Medical necessity requires Fintepla specifically (not alternatives)
  • Step therapy alternatives have failed or are contraindicated
  • Financial hardship makes current tier unaffordable

Documentation Needed

Your prescriber should include:

  • Clinical rationale for Fintepla over formulary alternatives
  • Prior medication trials with specific outcomes and adverse effects
  • Seizure frequency data before and during treatment trials
  • Quality of life impact documentation
  • Published evidence supporting Fintepla's unique benefits

Submission Process

Tier exception requests go through the same UnitedHealthcare provider portal as prior authorizations, with additional forms for cost-related appeals.

Specialty Pharmacy Coordination

OptumRx Requirements

UnitedHealthcare typically requires Fintepla dispensing through OptumRx specialty pharmacy:

  • 90-day supplies standard for specialty medications
  • Automatic refill programs available
  • Clinical support for REMS compliance and monitoring
  • Financial counseling for copay assistance enrollment

Coordination Tips

  1. Confirm pharmacy network before first fill
  2. Set up auto-refill to avoid gaps in therapy
  3. Schedule REMS echocardiograms in advance
  4. Coordinate with UCB copay program before each fill

Cost-Based Appeals

When Cost Appeals Apply

File a cost-based appeal when:

  • Tier placement seems inappropriate for medical necessity
  • Step therapy requirements ignore contraindications or failures
  • Quantity limits don't match FDA-approved dosing

Documentation for Cost Appeals

Include:

  • Prescriber attestation of medical necessity
  • Cost comparison with alternatives (if relevant)
  • Financial hardship documentation (if applicable)
  • Clinical guidelines supporting Fintepla's use

Annual Renewal Planning

What Changes Annually

  • Formulary tier placement (usually January 1)
  • Prior authorization criteria updates
  • Specialty pharmacy networks
  • Copay assistance program terms and income limits

Renewal Checklist

  • Review Summary of Benefits for formulary changes
  • Re-enroll in copay assistance programs (typically annual)
  • Update REMS enrollment if required
  • Schedule annual echocardiogram for continued coverage

Conversation Scripts

Calling UnitedHealthcare Member Services

"Hi, I'm calling about coverage for Fintepla, which is prescribed for my [child's/my] Dravet syndrome. Can you tell me the specialty coinsurance percentage and whether the deductible applies? I also need to know which specialty pharmacy I must use and if there are any quantity limits."

Requesting Peer-to-Peer Review

"I'd like to request a peer-to-peer review for the Fintepla prior authorization denial. The patient has documented treatment failures with [specific medications] and meets the clinical criteria outlined in your policy. When can we schedule this review?"

Pharmacy Coordination Call

"I'm calling to coordinate a Fintepla prescription that requires REMS enrollment and UCB copay assistance. Can you help me ensure both programs are active before dispensing?"

Pennsylvania Appeals Resources

Internal Appeals with UnitedHealthcare

  • Timeline: 180 days from denial to file
  • Process: Submit through provider portal or mail/fax
  • Response time: 72 hours for urgent, 30 days standard

Pennsylvania External Review Program

Pennsylvania's Independent External Review Program launched in 2024 with impressive results:

  • Success rate: Approximately 50% of appeals overturned
  • Timeline: 45 days for standard review, 72 hours for urgent
  • Cost: Free to consumers
  • Eligibility: Must complete internal appeals first

How to File External Review

  1. Complete internal appeals with UnitedHealthcare
  2. Receive Final Adverse Benefit Determination letter
  3. Submit request within 4 months at pa.gov/reviewmyclaim
  4. Include supporting documentation within 15 days of assignment

Pennsylvania Consumer Help

  • Pennsylvania Insurance Department Consumer Help: 1-877-881-6388
  • Pennsylvania Health Law Project: Free appeals assistance for low-income individuals
  • Pennie Consumer Hotline: For marketplace plan issues

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned with the plan's own policies, incorporating the right clinical evidence and procedural requirements to maximize approval chances.

FAQ

Q: How long does UnitedHealthcare prior authorization take for Fintepla? A: Standard PA decisions are typically made within 72 hours to 14 days. Urgent requests (when delays could seriously jeopardize health) are processed within 24-72 hours.

Q: What if Fintepla isn't on my UnitedHealthcare formulary? A: Non-formulary medications can still be covered through medical necessity appeals. Your prescriber will need to demonstrate why formulary alternatives are inappropriate.

Q: Can I get expedited appeals in Pennsylvania? A: Yes, both UnitedHealthcare internal appeals and Pennsylvania external reviews offer expedited timelines (72 hours) when health could be seriously jeopardized by delays.

Q: Does UCB copay assistance work with high-deductible plans? A: Yes, the ONWARD program can help with coinsurance and deductible costs for commercially insured patients, but verify current terms when enrolling.

Q: What happens if I move out of Pennsylvania during an appeal? A: Contact the Pennsylvania Insurance Department at 1-877-881-6388 to understand how state changes affect ongoing external reviews.

Q: Can I appeal both medical necessity and cost simultaneously? A: Yes, appeals can address multiple denial reasons. Include documentation for both medical necessity and financial hardship if relevant.

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 company for personalized guidance. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department at 1-877-881-6388.

Whether you're navigating prior authorization requirements or preparing for appeals, Counterforce Health can help you build stronger cases by analyzing denial patterns and crafting evidence-backed responses that align with UnitedHealthcare's specific policies and Pennsylvania's regulatory requirements.

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