CurrentCignaPolicy CNF315

Antiseizure Medications - Fintepla Prior Authorization Policy

Defines Cigna's prior authorization requirements and coverage criteria for Fintepla (fenfluramine oral solution) for treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome for applicable benefit plans.

Policy Summary

PayerCigna

PolicyAntiseizure Medications - Fintepla Prior Authorization Policy

Policy CodePolicy CNF315

Change TypeNo material change

Effective Date

Next Review DateApr 23, 2025

Key ActionObtain prior authorization with documentation of age (≥2 years), indication, prior/concomitant antiseizure medication history, and neurologist prescribing or consultation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2FDA-approved indications covered

1 yearTypical approval duration

≥2Minimum patient age

neurologistPrescriber specialty

Coverage Criteria for Fintepla (fenfluramine)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Dravet - initial or current: A) Initial Therapy: approve if ALL of (i, ii, iii) OR B) Currently receiving: approve if responding to therapy

Dravet Initial (A): i. Patient is >= 2 years of age; AND ii. Patient meets ONE of: a) Patient has tried or is concomitantly receiving at least two other antiseizure medications; OR b) Patient has tried or is concomitantly receiving one of clobazam, Epidiolex (cannabidiol), or Diacomit (stiripentol); AND iii. Fintepla is prescribed by or in consultation with a neurologist

Examples of other antiseizure medications include valproic acid, topiramate, clonazepam, levetiracetam, zonisamide.

Dravet Continuation (B): Patient is currently receiving Fintepla and is responding to therapy as determined by the prescriber (e.g., reduced seizure severity, frequency, and/or duration)

Lennox-Gastaut Syndrome

Covered when ONE of the following is met for Lennox-Gastaut syndrome (approve for 1 year):

LGS - initial or current: A) Initial Therapy: approve if ALL of (i, ii, iii) OR B) Currently receiving: approve if responding to therapy

LGS Initial (A): i. Patient is >= 2 years of age; AND ii. Patient has tried or is concomitantly receiving at least two other antiseizure medications; AND iii. The medication is prescribed by or in consultation with a neurologist

Examples of other antiseizure medications include clobazam, Epidiolex (cannabidiol), felbamate, lamotrigine, rufinamide, topiramate, valproic acid, levetiracetam, zonisamide, perampanel, vigabatrin.

LGS Continuation (B): Patient is currently receiving Fintepla and is responding to therapy as determined by the prescriber (e.g., reduced seizure severity, frequency, and/or duration)

Conditions not covered for Fintepla are listed under the policy section titled CONDITIONS NOT COVERED. This section identifies products or uses that are not eligible for coverage under the applicable benefit plan; in this document the entry under CONDITIONS NOT COVERED lists Fintepla® (fenfluramine oral solution - Zogenix). Providers should reference the member’s specific benefit plan and the full policy for any plan-specific exclusions or coverage limitations.

Coding and Product Information

Covered NDC / productNDCCovered

NDC	Fintepla (fenfluramine oral solution) product billing via NDC

Minimum age — Fintepla (fenfluramine)

Minimum age>= 2 years

Approval durationApprove for 1 year when criteria met

Applies to indicationsDravet syndrome and Lennox-Gastaut syndrome

Documentation neededPatient age must be documented as ≥ 2 years

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Fintepla (fenfluramine oral solution) prescription benefit coverage. All approvals are provided for the duration noted in the policy. Initial approval requires the medication to be prescribed by or in consultation with a physician who specializes in the condition being treated (e.g., neurologist).

Prior authorization required for Fintepla
Approvals provided for the duration specified in the policy (e.g., 1 year for FDA indications)
Initial prescription must be by or in consultation with a specialist in the treated condition (neurologist)

Step Therapy

Provider Actions — Initial Therapy Requirements

For initial therapy, documentation must show that the patient meets age and medication-trial requirements prior to approval.

Patient age: documentation must show patient is ≥ 2 years of age.
Trials/concomitant therapy: for Dravet and Lennox-Gastaut syndromes, patient must have tried or be concomitantly receiving at least two other antiseizure medications OR have tried/receive one of the specified alternatives (clobazam, Epidiolex/cannabidiol, or Diacomit/stiripentol) as detailed in the policy.
Specialist prescribing: Fintepla must be prescribed by or in consultation with a neurologist for initial therapy.

Documentation Required

Provider Actions — Documentation and Claims/Billing Compliance

Document and submit supporting clinical information with the prior authorization request. Claims submitted without required covered diagnosis/procedure codes or not in accordance with the benefit plan may be denied.

Required documentation: patient age (≥ 2 years), diagnosis (e.g., Dravet syndrome or Lennox-Gastaut syndrome), prior or concomitant antiseizure medication history (including names and dates), and prescriber specialty or consultation note (neurologist) for initial therapy.
Continuation therapy: document clinical response to Fintepla (e.g., reduced seizure frequency, severity, and/or duration) when requesting renewal.
Billing/claims note: claims submitted without covered diagnosis or procedure codes or not submitted per the applicable benefit plan may be denied.

Background

Fintepla (fenfluramine) is a serotonin 5‑HT2 agonist indicated for the treatment of seizures associated with Dravet syndrome and Lennox‑Gastaut syndrome in patients aged ≥ 2 years. Prior authorization is recommended for Fintepla, and approvals are typically issued for 1 year. For initial therapy, the policy requires that patients meet syndrome‑specific criteria such as prior or concomitant antiseizure medication trials and that the medication be prescribed by or in consultation with a neurologist; continuation approvals require documentation of clinical response while receiving Fintepla.

Key Definitions

Dravet syndrome — definition

DefinitionA rare genetic epileptic encephalopathy beginning in the first year of life with frequent and/or prolonged seizures

Typical onsetSeizures generally begin in the first year of life

Seizure characteristicsMultiple seizure types (myoclonic, tonic‑clonic, absence, atypical absence, atonic, focal aware or impaired awareness, status epilepticus)

Treatment responseSeizures are often refractory to medications and commonly require two or more antiseizure medications

Coverage actionCovered indication for Fintepla when Dravet criteria are met (approve for 1 year)

Lennox‑Gastaut syndrome — definition

DefinitionA severe epileptic and developmental encephalopathy characterized by multiple seizure types and high morbidity

Typical onsetMost often begins between ages 3 and 5 years

Seizure typesCommonly atonic and tonic seizures; multiple other seizure types may occur

Treatment characteristicsOften resistant to therapy; typically requires combination therapy with two or more antiseizure medications

Coverage actionCovered indication for Fintepla when LGS criteria are met (approve for 1 year)