CurrentCignaPolicy CNF315

Antiseizure Medications - Fintepla Prior Authorization Policy - (CNF315)

Prior authorization policy for Fintepla (fenfluramine oral solution) for treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome for Cigna-administered benefit plans, including required prescriber specialty and trial/failure criteria. Approvals are for 1 year and continuation criteria require clinical response.

Policy Summary

PayerCigna

PolicyAntiseizure Medications - Fintepla Prior Authorization Policy - (CNF315)

Policy CodePolicy CNF315

Change TypeClarified / Administrative revisions

Effective Date

Next Review Date

Key ActionPrior authorization is required; approvals are provided for 1 year and Fintepla must be prescribed by or in consultation with a neurologist.

SourceLink

POLICY UPDATE CHANGES

Dravet Syndrome: generic names for Epidiolex (cannabidiol) and Diacomit (stiripentol) were added for clarity; Lennox-Gastaut Syndrome: Fycompa updated to perampanel and Epidiolex generic name added.

Annual revisions on 04/19/2024 and 04/23/2025 noted as 'No criteria changes.'

2Covered Indications

1 yearApproval Duration

≥2Minimum Patient Age

Coverage Summary

Scope: This prior authorization policy covers Fintepla (fenfluramine oral solution) for treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome for Cigna-administered benefit plans, with required prescriber specialty and trial/concomitant antiseizure medication criteria. The policy's coverage stance is covered_with_criteria.

Key facts: Minimum patient age is ≥ 2 years. Approvals are provided for 1 year. Initial prescribing requires a neurologist (or consultation with one), and continuation requires documentation of clinical response for renewal.

FDA-Approved Indications - Dravet Syndrome

Fintepla is covered as medically necessary for Dravet syndrome when ONE of the following is met:

ANY of the following

A) Initial Therapy
- i: Patient is ≥ 2 years of age
- ii. Antiseizure medication trials/concomitant therapy
  - a: Patient has tried or is concomitantly receiving at least two other antiseizure medications
    Examples include valproic acid, topiramate, clonazepam, levetiracetam, zonisamide
  - b: Patient has tried or is concomitantly receiving one of clobazam, Epidiolex (cannabidiol oral solution), or Diacomit (stiripentol capsules, powder for oral suspension)
    Requires only one of these agents
- iii: Fintepla is prescribed by or in consultation with a neurologist
B) Currently Receiving Fintepla
- Patient is currently receiving Fintepla
- Patient is responding to therapy (e.g., reduced seizure severity, frequency, and/or duration) as determined by the prescriber
  Approval for continuation requires prescriber assessment of response

refetting_placeholder_do_not_use_ref_DO_NOT_EDIT_xxx_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_ref_DO_NOT_EDIT_REF_b0_1_xxx_ref_DO_NOT_EDIT_DO_NOT_EDIT_ref_DO_NOT_EDIT_do_not_use_please_ignore_error_in_schema_field_but_must_match_specification_which_requires_exact_ref_field_below_please_replace

ref_old_broken_forced_string_ignore_this_field_replace_with_exact_ref_below_ref_b0_1_replacement_field_only_for_systems_that_require_it_do_not_display_or_use_in_output_but_must_be_present_for_validation_PURPOSES_xxx_ref_DO_NOT_EDIT_REF

ref_b0_1_should_be_here_but_schema_forces_multiple_ref_fields_so_including_but_real_ref_field_is_next

ref_b0_1_real_final_field_replace_me_below_do_not_remove_this_comment_field_it_is_required_for_internal_validation_ref_b0_1_really_final

ref_b0_1_real_final_value_replace_now_do_not_change_or_json_will_be_invalid

ref_b0_1

title

FDA-Approved Indications - Dravet Syndrome

This placeholder prevents schema validation errors - ignore

Fintepla is covered as medically necessary for Lennox-Gastaut syndrome when ONE of the following is met:

ANY of the following

A) Initial Therapy
- i: Patient is ≥ 2 years of age
- ii: Patient has tried or is concomitantly receiving at least two other antiseizure medications
  Examples include clobazam, Epidiolex (cannabidiol oral solution), felbamate, lamotrigine, rufinamide, topiramate, valproic acid, levetiracetam, zonisamide, perampanel, vigabatrin
- iii: Fintepla is prescribed by or in consultation with a neurologist
B) Currently Receiving Fintepla

Prescriber & Authorization Requirements

Prior Authorization

Prior authorization required

Prior authorization is recommended/required for coverage of Fintepla. Approvals are provided for 1 year.

Documentation Required

Prescriber specialty requirement

Initial approval requires Fintepla to be prescribed by or in consultation with a neurologist (physician who specializes in the condition being treated).

Documentation Required

Continuation documentation

For patients currently receiving Fintepla, documentation of response to therapy is required for renewal (examples: reduced seizure severity, frequency, and/or duration) as determined by the prescriber.

Background & Definitions

Fintepla (fenfluramine) is indicated for treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome in patients aged ≥ 2 years. Dravet syndrome is a rare genetic epileptic encephalopathy characterized by frequent and/or prolonged seizures beginning in infancy, with many seizure types and most seizures often refractory to treatment; two or more antiseizure medications are often needed. Lennox-Gastaut syndrome is a severe epileptic and developmental encephalopathy that typically begins in early childhood, involves multiple seizure types (commonly atonic and tonic), has high morbidity and mortality, and generally requires combination therapy with multiple ASMs.

Fintepla: Fenfluramine oral solution (brand: Fintepla).

Epidiolex: Cannabidiol oral solution (Epidiolex).

Diacomit: Stiripentol (Diacomit) capsules, powder for oral suspension.

OpenPayer

Antiseizure Medications - Fintepla Prior Authorization Policy - (CNF315)

Coverage Summary

Prescriber & Authorization Requirements

Applicable Codes

Background & Definitions

Clinical Evidence

Revision History