By Counterforce Health Team in Fintepla (fenfluramine) —

Work With Your Doctor to Get Fintepla (Fenfluramine) Approved by Blue Cross Blue Shield in California: Complete Provider Collaboration Guide

Answer Box: Getting Fintepla Approved in California

Fintepla (fenfluramine) requires prior authorization from Blue Cross Blue Shield California, including REMS enrollment documentation and echocardiogram results to confirm eligibility for Dravet or Lennox-Gastaut syndrome. Your doctor must first enroll as a prescriber and enroll you as a patient at FinteplaREMS.com, obtain baseline echocardiography, and document failure of 2-3 anti-seizure medications. If denied, California offers Independent Medical Review (IMR) through the DMHC with no patient fees and high success rates for medically necessary specialty drugs.

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

Table of Contents

  1. Set Your Goal: What Approval Requires
  2. Visit Preparation: Organizing Your Medical History
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After-Visit Documentation
  7. Respectful Persistence and Escalation
  8. California Appeals Process
  9. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization BCBS CA requires approval before coverage Provider portal BCBS CA Policy
REMS Enrollment Mandatory safety program enrollment FinteplaREMS.com FDA Requirement
Step Therapy Must try 2-3 other seizure medications first Insurance formulary Plan Documents
Echocardiogram Baseline and every 6 months Cardiology or neurology clinic REMS Protocol
Specialist Prescription Neurologist or epilepsy specialist required Provider credentials PA Criteria
Appeals Deadline 30 days for internal, then IMR available DMHC Help Center California Law

Set Your Goal: What Approval Requires

Getting Fintepla covered by Blue Cross Blue Shield in California requires a strategic partnership between you and your doctor. The medication treats seizures in Dravet syndrome (ICD-10: G40.83) and Lennox-Gastaut syndrome (ICD-10: G40.82) but comes with strict requirements due to heart valve risks.

Your doctor must complete these steps before prescribing:

  1. REMS Prescriber Certification: Complete training and assessment at FinteplaREMS.com
  2. Patient REMS Enrollment: Enroll you in the safety monitoring program
  3. Baseline Echocardiogram: Order and review heart ultrasound results
  4. Prior Authorization Submission: Document diagnosis and previous medication failures

Your role as the patient:

  • Provide complete seizure and medication history
  • Consent to REMS enrollment and ongoing heart monitoring
  • Gather insurance information and previous medical records
  • Stay engaged throughout the approval process
Note: The entire process typically takes 2-4 weeks from REMS enrollment to insurance approval, assuming all documentation is complete.

Visit Preparation: Organizing Your Medical History

Before your appointment, create a comprehensive timeline that will help your doctor build the strongest possible case for medical necessity.

Seizure History Documentation:

  • Age when seizures first started (crucial for Dravet/LGS diagnosis)
  • Types of seizures experienced (tonic, clonic, absence, myoclonic)
  • Current seizure frequency and severity
  • Triggers you've identified (fever, light patterns, stress)
  • Emergency room visits or hospitalizations

Medication Trial History: Document each anti-seizure medication tried, including:

  • Medication name and generic equivalent
  • Dates started and stopped
  • Highest dose reached
  • Reason for discontinuation (ineffective, side effects, allergic reaction)
  • Specific side effects experienced

Functional Impact Notes:

  • How seizures affect daily activities, school, or work
  • Developmental delays or cognitive changes
  • Quality of life impacts for you and your family
  • Safety concerns (falls, driving restrictions, supervision needs)
Tip: Bring a written timeline to your appointment. Your doctor can use this information directly in the medical necessity letter, and it ensures nothing important is forgotten during the visit.

Building Your Evidence Kit

Your doctor needs specific evidence to justify Fintepla's medical necessity. Help gather these materials before your appointment:

Diagnostic Evidence:

  • EEG reports showing seizure patterns consistent with Dravet or LGS
  • Genetic testing results (especially SCN1A mutations for Dravet syndrome)
  • Brain MRI or other imaging studies
  • Neuropsychological testing results

Treatment History Documentation:

  • Pharmacy records showing filled prescriptions for previous seizure medications
  • Hospital discharge summaries from seizure-related admissions
  • Emergency department records
  • Previous neurologist notes and recommendations

Laboratory Results:

  • Recent blood work (CBC, comprehensive metabolic panel, liver function)
  • Drug levels for current medications
  • Any monitoring labs from previous treatments

Supporting Guidelines: Your doctor may reference these clinical sources in the medical necessity letter:

Medical Necessity Letter Structure

A well-structured medical necessity letter addresses each insurance requirement systematically. Here's what your doctor should include:

1. Patient and Provider Information

  • Your full name, date of birth, and insurance ID
  • Doctor's credentials and specialty certification
  • Date of letter and urgency level

2. Diagnosis Documentation

  • Specific epilepsy syndrome (Dravet or Lennox-Gastaut)
  • ICD-10 diagnostic codes
  • Age of onset and seizure characteristics
  • Supporting test results (EEG, genetic testing)

3. Treatment History and Rationale

  • Table of previous anti-seizure medications with outcomes
  • Contraindications to formulary alternatives
  • Clinical rationale for Fintepla specifically
  • Expected benefits and treatment goals

4. Safety Monitoring Plan

  • REMS enrollment confirmation
  • Echocardiogram schedule (baseline and every 6 months)
  • Ongoing neurological monitoring
  • Emergency action plan

5. Supporting References

  • FDA approval for patient's specific condition
  • Clinical trial data showing efficacy
  • Professional society guidelines
  • Peer-reviewed literature
Clinician Corner: The medical necessity letter should emphasize that Fintepla represents the next appropriate step in the treatment algorithm for refractory Dravet or LGS, not just another option to try. Frame it as evidence-based progression rather than experimental therapy.

Supporting Peer-to-Peer Reviews

If Blue Cross Blue Shield requests a peer-to-peer review, you can help your doctor prepare for this important conversation with the insurance medical director.

Key Talking Points for Your Doctor:

  • Emphasize that Fintepla has FDA approval specifically for your diagnosed condition
  • Highlight previous medication failures and why alternatives aren't suitable
  • Stress the risks of continued uncontrolled seizures
  • Reference REMS compliance as evidence of appropriate safety monitoring

How You Can Support:

  • Offer flexible scheduling for the peer-to-peer call
  • Provide a one-page summary of your seizure impact
  • Be available by phone in case the medical director wants to speak with you directly
  • Prepare specific examples of how current medications aren't working

Documentation to Have Ready:

  • Recent seizure diary or frequency log
  • Emergency department visits in the past 6 months
  • Current medication list with doses and timing
  • Quality of life impact statement

When working with Counterforce Health, many patients find that having professional support during peer-to-peer reviews significantly improves approval rates. The platform helps organize clinical evidence and provides talking points that align with payer-specific criteria.

After-Visit Documentation

After your appointment, ensure all necessary paperwork is properly submitted and tracked.

What to Save:

  • Copy of the medical necessity letter
  • REMS enrollment confirmations for both you and your doctor
  • Echocardiogram reports and interpretation
  • Prior authorization submission confirmation
  • Any correspondence from Blue Cross Blue Shield

Patient Portal Communication:

  • Message your doctor through the patient portal to confirm submission dates
  • Request copies of all documents submitted to insurance
  • Ask for the prior authorization reference number
  • Clarify timeline expectations for insurance response

Follow-Up Schedule:

  • Week 1: Confirm REMS enrollment completion
  • Week 2: Check prior authorization status
  • Week 3: If no response, request status update from insurance
  • Week 4: If denied, begin appeal preparation immediately

Respectful Persistence and Escalation

Insurance approvals often require persistent but professional follow-up. Here's how to maintain momentum without straining relationships:

Weekly Check-In Protocol:

  • Monday morning: Check insurance portal for updates
  • Wednesday: Contact doctor's office if no news
  • Friday: Call Blue Cross Blue Shield member services if needed

Escalation Triggers:

  • No response after 15 business days (standard processing time)
  • Request for additional documentation not mentioned in policy
  • Denial based on criteria you've already met
  • Delays that affect your health or safety

Professional Communication Scripts:

For insurance follow-up: "I'm calling to check on the status of prior authorization request [reference number] for Fintepla submitted on [date]. Can you provide an update on the review timeline?"

For doctor's office: "I wanted to follow up on my Fintepla prior authorization. Has the insurance company requested any additional information, and is there anything I can help provide?"

California Appeals Process

California offers robust protections for patients denied specialty medications. If Blue Cross Blue Shield denies your Fintepla request, you have strong appeal rights.

Internal Appeal (First Level):

  • Timeline: Must file within 30 days of denial
  • Process: Submit appeal letter with additional evidence
  • Decision deadline: 30 days for standard, 72 hours for expedited
  • Required documents: Denial letter, medical necessity letter, clinical notes

Independent Medical Review (IMR):

  • When available: After internal appeal denial or 30-day delay
  • Cost: Free to patients
  • Timeline: 45 days for standard, 7 days for expedited
  • Decision authority: Independent physician specialists
  • Success rate: High for medically necessary treatments

How to Request IMR:

  1. Contact DMHC Help Center at 888-466-2219
  2. Complete IMR application online or by mail
  3. Submit all medical records and supporting documentation
  4. DMHC assigns independent medical expert for review
Important: California's IMR process is binding on insurance companies. If the independent review determines Fintepla is medically necessary, Blue Cross Blue Shield must approve coverage.

Patients working with Counterforce Health often see improved outcomes in California appeals because the platform helps organize evidence according to state-specific requirements and payer policies.

FAQ

How long does Blue Cross Blue Shield prior authorization take in California? Standard processing is 15 business days, but can be expedited to 72 hours if your doctor certifies urgent medical need due to seizure risks.

What if Fintepla isn't on my formulary? You can request a formulary exception if your doctor documents medical necessity and previous medication failures. Non-formulary status doesn't prevent coverage if medically justified.

Can I request expedited appeal? Yes, if delays could jeopardize your health. Uncontrolled seizures often qualify for expedited review in California.

Does step therapy apply if I tried medications in another state? Yes, medication trials from any location count toward step therapy requirements. Provide pharmacy records or medical notes as documentation.

What financial assistance is available? The Fintepla Copay Program may reduce costs to $0 for eligible commercially insured patients. PAF Co-Pay Relief provides additional assistance based on income.

How often do I need echocardiograms? Baseline before starting, then every 6 months during treatment, and 3-6 months after stopping Fintepla per REMS requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. Insurance coverage policies change frequently; verify current requirements with your specific Blue Cross Blue Shield plan. For assistance with complex appeals, consider consulting with patient advocacy organizations or services like Counterforce Health that specialize in insurance coverage for specialty medications.

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