Anthem Blue Cross (HMO, PPO, EPO)
Fintepla (fenfluramine)
Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain
  • Dravet Syndrome, Lennox Gastaut Syndrome (LGS):
    Age Requirement: >= 2
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Neurology: Epilepsy:
    Age Requirement: >= 2
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Diagnosis Type(s): 1 of Dravet syndrome;Seizures Associated with Lennox-Gastaut Syndrome (LGS)
    Used as Adjunctive Treatment: No
    Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: N/A
    Documented history of persisting seizures after titration to highest tolerated dose of each AED.: No
    Lack of compliance as a reason for treatment failure has been ruled out: No
    Documentation of treatment failure due to intolerable side effects.: No
    Positive Response to Therapy Required for Reauth: No
    Treatment for Age 17 years or older: No
    Treatment for Age 1-16 years old: Yes
    History of >= to 30 day trial of other AED required: No
    Reapproval based on response: No

  • Prior Authorization: Documented Diagnosis: Yes
    Age Requirement: >= 2
    Duration: 1 year(s)

  • Quantity Limit: 26 mg per 1 day(s).
  • Step Therapy: Dravet Syndrome, Neurology: Epilepsy:
    ST Multiple Generics

    Lennox Gastaut Syndrome (LGS):
    Step Therapy Applies

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