By Counterforce Health Team in Filspari (sparsentan) —

Filspari (Sparsentan) Approval with Cigna in New Jersey: Complete Guide to Prior Authorization, Appeals, and Coverage

Answer Box: Getting Filspari Covered by Cigna in New Jersey

Filspari (sparsentan) requires prior authorization from Cigna for IgA nephropathy treatment. To get coverage in New Jersey: (1) Have your nephrologist submit a PA with biopsy-confirmed IgAN diagnosis, persistent proteinuria ≥0.8 g/g UPCR despite 12+ weeks of ACE inhibitor/ARB, and REMS enrollment documentation. (2) If denied, file internal appeals within 180 days, then use New Jersey's IHCAP external review through Maximus Federal Services for a binding decision. (3) Start by calling Cigna at the number on your ID card to confirm formulary status and PA requirements for your specific plan.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Clinical Criteria
  5. Costs and Specialty Pharmacy
  6. Denials and Appeals
  7. New Jersey External Review (IHCAP)
  8. Renewals and Continuing Coverage
  9. Troubleshooting Common Issues
  10. FAQ

Coverage Basics

Is Filspari Covered by Cigna?

Yes, Filspari (sparsentan) is covered by Cigna when medical necessity criteria are met. Cigna has a national coverage policy for Filspari that applies to most commercial plans, including those in New Jersey.

Key coverage facts:

  • Prior authorization required for all Filspari prescriptions
  • Specialty tier placement with coinsurance (typically 20-50% of drug cost)
  • Specialty pharmacy dispensing often through Accredo
  • REMS program compliance mandatory

Which Cigna Plans Cover Filspari?

Filspari coverage applies to:

  • Commercial employer plans
  • Individual/family plans (ACA marketplace)
  • Some Cigna Medicare Advantage plans (check formulary)

Not typically covered:

  • Self-funded employer plans may have different rules
  • Medicare Part D standalone plans vary by carrier
Tip: Call the number on your Cigna ID card and ask: "Is Filspari on my plan's formulary, and what's my prior authorization process?"

Prior Authorization Process

Who Submits the Prior Authorization?

Your nephrologist or prescribing clinic submits the PA to Cigna. Patients cannot submit medical PAs directly.

Step-by-Step: Fastest Path to Approval

  1. Verify benefits (Patient/Clinic): Call Cigna to confirm Filspari is on formulary with PA
  2. Gather documentation (Clinic): Collect biopsy report, labs, prior therapy records
  3. Submit PA (Prescriber): Use Cigna's electronic PA portal or fax forms
  4. Include REMS attestation (Prescriber): Confirm enrollment in Filspari REMS program
  5. Track submission (Clinic): Follow up within 3-5 business days
  6. Request peer-to-peer (Prescriber): If initial denial, immediately request P2P review
  7. Appeal if denied (Patient/Prescriber): File within 180 days with clinical justification

Timing and Deadlines

Request Type Decision Timeline Appeal Deadline
Standard PA 30 calendar days 180 days from denial
Expedited PA 72 hours 180 days from denial
Internal Appeal Level 1 30 days 180 days from original denial
Internal Appeal Level 2 30 days 60 days from Level 1 decision
NJ External Review (IHCAP) 45 days (standard) / 48 hours (expedited) 4 months from final internal denial

Sources: Cigna Appeals Process, NJ IHCAP Guidelines

When to Request Expedited Review

Request expedited (urgent) review if delay in starting Filspari could:

  • Cause serious deterioration in health
  • Jeopardize ability to regain maximum function
  • Subject you to severe pain

Your nephrologist must provide clinical justification for urgency.

Clinical Criteria

Medical Necessity Requirements for IgA Nephropathy

Cigna's Filspari coverage policy requires all of the following:

Patient criteria:

  • Age ≥18 years
  • Biopsy-confirmed primary IgA nephropathy
  • Persistent proteinuria (UPCR ≥0.8 g/g or 24-hour protein ≥0.5 g/day)
  • Maximum tolerated ACE inhibitor or ARB for ≥12 weeks
  • Treatment by or consultation with a nephrologist

REMS requirements:

  • Prescriber enrolled in Filspari REMS program
  • Baseline liver function tests (ALT, AST, bilirubin)
  • Plan for quarterly LFT monitoring
  • Pregnancy prevention counseling (if applicable)
Clinician Corner: Include the exact UPCR value and date, ACE inhibitor/ARB dose and duration, and confirm REMS enrollment status in your PA submission. Cigna specifically looks for quantitative proteinuria documentation.

Common Missing Documentation

Top reasons for PA delays:

  • Missing kidney biopsy pathology report
  • No quantitative proteinuria (UPCR or 24-hour protein)
  • Insufficient documentation of ACE inhibitor/ARB trial
  • REMS enrollment not confirmed
  • eGFR not provided or outside acceptable range

Costs and Specialty Pharmacy

Expected Out-of-Pocket Costs

Filspari is typically placed on Cigna's specialty tier with coinsurance rather than flat copays:

  • Commercial plans: 20-50% coinsurance (varies by plan)
  • List price: Approximately $9,900-$10,038 per 30-day supply
  • Your cost: Depends on deductible, out-of-pocket maximum, and coinsurance rate

Specialty Pharmacy Requirements

Most Cigna plans require Filspari to be dispensed through Accredo (Cigna's specialty pharmacy) or another designated specialty pharmacy.

Process:

  1. Prescriber sends approved prescription to Accredo
  2. Accredo contacts you for benefit verification
  3. They provide cost estimate and shipping arrangements
  4. Medication ships directly to your home

Accredo contact: Check your Cigna ID card or call member services for current contact information.

Cost Assistance Options

  • Travere Therapeutics copay support: May reduce costs for commercially insured patients (verify current link with the source linked below)
  • Non-profit foundations: Check kidney disease foundations for IgA nephropathy assistance
  • State programs: New Jersey may have additional assistance programs

Note: Medicare patients typically cannot use manufacturer copay cards

Denials and Appeals

Common Denial Reasons and Solutions

Denial Reason How to Overturn
"Not medically necessary" Submit updated clinical notes showing disease severity, failed prior therapies
"Experimental/investigational" Provide FDA approval documentation, clinical guidelines supporting use
"Step therapy required" Document contraindications or failures of required first-line therapies
"REMS not enrolled" Confirm prescriber REMS enrollment, submit attestation
"Insufficient proteinuria" Provide recent UPCR ≥0.8 g/g or 24-hour protein ≥0.5 g/day

Cigna Internal Appeals Process

Level 1 Appeal:

  • Who can file: Patient, prescriber, or authorized representative
  • How to file: Cigna appeals portal or written request
  • Timeline: Must file within 180 days of denial
  • Decision: Within 30 days

Level 2 Appeal:

  • When to use: If Level 1 appeal is denied
  • Timeline: Must file within 60 days of Level 1 decision
  • Review: Different medical director reviews case
  • Decision: Within 30 days

Peer-to-Peer Review Strategy

Request P2P immediately upon denial. Have your nephrologist prepared with:

  • Specific clinical rationale addressing denial reason
  • Guideline citations supporting Filspari use
  • Documentation of failed alternatives
  • Patient-specific factors making Filspari necessary

New Jersey External Review (IHCAP)

If Cigna's internal appeals are exhausted, New Jersey residents have access to the Independent Health Care Appeals Program (IHCAP), administered by Maximus Federal Services.

IHCAP Eligibility

You can use IHCAP if:

  • Your plan is fully insured in New Jersey (not self-funded/ERISA)
  • Cigna denied Filspari based on medical necessity or experimental/investigational determination
  • You completed Cigna's internal appeal process (or qualify for bypass)

How to File with IHCAP

  1. Complete external appeal application: Download from NJ DOBI website
  2. Submit to Maximus: Use their online portal or mail/fax
  3. Include required documents:
    • Cigna denial letters (Level 1 and 2)
    • Medical records supporting Filspari necessity
    • Prescriber letter of medical necessity
    • Signed consent and medical records release forms

IHCAP Decision Process

  • Preliminary review: Maximus determines eligibility within 5 business days
  • Full review: Independent medical experts review case
  • Timeline: 45 days (standard) or 48 hours (expedited)
  • Decision: Binding on Cigna - they must comply if overturned
  • Cost: Free to patients
Note: IHCAP has strong success rates for appropriately documented specialty drug appeals when clear medical necessity exists.

When preparing for IHCAP, Counterforce Health can help patients and clinicians build comprehensive appeals packages that address specific payer denial reasons with targeted clinical evidence. Their platform specializes in turning insurance denials into successful appeals by identifying the exact coverage criteria and building point-by-point rebuttals with appropriate medical literature.

Renewals and Continuing Coverage

When to Reauthorize

Cigna typically approves Filspari for 12-month periods. Start the renewal process 30-60 days before expiration.

Renewal Requirements

Documentation needed:

  • Updated clinical notes showing treatment response
  • Recent labs (proteinuria, eGFR, liver function tests)
  • Confirmation of ongoing REMS compliance
  • No significant safety issues

Treatment response evidence:

  • Reduction in proteinuria (even if not to normal levels)
  • Stable or improved eGFR
  • Overall clinical stability or improvement

Troubleshooting Common Issues

Portal or System Problems

If Cigna's PA portal is down:

  • Fax PA forms to the number on denial letters
  • Call provider services for alternative submission methods
  • Document submission attempts for appeal purposes

Missing Forms or Information

For incomplete PA submissions:

  • Cigna typically requests additional information within 5-10 days
  • Respond promptly to avoid delays
  • Keep copies of all submitted documentation

Prescription Transfer Issues

If your prescription was transferred to specialty pharmacy:

  • This is standard for specialty drugs like Filspari
  • Contact the specialty pharmacy directly for status updates
  • Ensure they have current insurance and contact information

FAQ

How long does Cigna prior authorization take for Filspari in New Jersey? Standard PA decisions take up to 30 days. Expedited requests (when medically urgent) are decided within 72 hours.

What if Filspari is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification. Your prescriber must demonstrate medical necessity and that formulary alternatives are inappropriate.

Can I request an expedited appeal in New Jersey? Yes, both Cigna internal appeals and IHCAP external review offer expedited timelines when delay could seriously jeopardize health.

Does step therapy apply if I failed similar drugs outside New Jersey? Yes, documented failures of ACE inhibitors, ARBs, or other required therapies from any provider should count toward step therapy requirements.

What happens if I move from New Jersey while on Filspari? Your coverage continues under the same Cigna plan, but appeal rights may change based on your new state's external review laws.

How do I know if my employer plan is eligible for IHCAP? Check with HR or benefits administrator. Self-funded/ERISA plans typically are not eligible for state external review programs like IHCAP.

Can my doctor appeal on my behalf? Yes, prescribers can file appeals for patients with proper authorization. This is often more effective as they have direct access to medical records.

What if Cigna approves Filspari but my pharmacy can't get it? Contact Cigna to confirm which specialty pharmacies are in-network for your plan. You may need to transfer to an approved specialty pharmacy like Accredo.

Glossary

  • PA (Prior Authorization): Insurance approval required before dispensing certain medications
  • REMS: Risk Evaluation and Mitigation Strategy - FDA safety program for certain drugs
  • UPCR: Urine protein-to-creatinine ratio - lab test measuring kidney protein loss
  • P2P: Peer-to-peer review between prescriber and insurance medical director
  • IHCAP: Independent Health Care Appeals Program - New Jersey's external review process
  • Step Therapy: Requirement to try less expensive drugs before approving more costly options

This guide is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. For personalized assistance, contact the New Jersey Department of Banking and Insurance at 1-800-446-7467 or your Cigna member services.

Sources & Further Reading:

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