Coverage Policies

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Effective Date: 01/01/2021 Title: Fintepla (fenfluramine)
Revision Date: Document: BI674:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Fintepla (fenfluramine) requires prior authorization.

2)    Fintepla is used to treat seizures associated with Dravet syndrome (DS) in patients 2 years of age and older.

3)    Fintepla is covered under the pharmacy benefit.

Medical Statement

Fintepla (fenfluramine) is considered medically necessary for members meeting the following criteria:


Dravet Syndrome (must meet all)

1)    Diagnosis of Dravet syndrome (DS);

2)    Prescribed by or in consultation with a neurologist;

3)    Age > 2 years;

4)    Will be used as adjunctive therapy with at least one other antiepileptic agent;

5)    Dose does not exceed either of the following (a or b):

a.    Members not on concomitant Diacomit: 26mg (12ml) per day;

b.    Members on concomitant Diacomit plus clobazam: 17mg (8ml) per day.

Approval Duration: 12 months

Reauthorization (12 months) must meet all

1)    Member is responding positively to therapy;

2)    Fintepla will continue to be used as adjunctive therapy with at least one other antiepileptic agent.


1)    Fintepla Prescribing Information. Emeryville, CA: Zogenix Inc.; June 2020.

2)    Wirrell EC, Laux L, Jette N, et al. Optimizing the diagnosis and management of Dravet syndrome: recommendations from a North American consensus panel. Pediatr Neurol. 2017; 68: 18-34.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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