By Counterforce Health Team in Filspari (sparsentan) —

Get Filspari (Sparsentan) Covered by Aetna CVS Health in Pennsylvania: Complete Guide to Prior Authorization and Appeals

Answer Box: Quick Path to Filspari Coverage

Getting Filspari (sparsentan) covered by Aetna CVS Health in Pennsylvania requires:

  1. Biopsy-proven IgA nephropathy diagnosed by a nephrologist
  2. Failed ACE inhibitor/ARB therapy (≥3 months unless contraindicated)
  3. REMS enrollment with quarterly liver function tests
  4. Prior authorization submission with complete clinical documentation

First step today: Contact your nephrologist's office to confirm they have your kidney biopsy report, recent UPCR/eGFR labs, and documentation of prior ACE inhibitor or ARB failure. This forms the foundation of your PA request.

If denied, Pennsylvania's new external review program has a 50% overturn rate for appealed denials.

Table of Contents

  1. Is Filspari Covered by Aetna CVS Health?
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Clinical Criteria Requirements
  5. Cost Considerations
  6. Denials and Appeals
  7. Renewal Requirements
  8. CVS Specialty Pharmacy
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Is Filspari Covered by Aetna CVS Health?

Filspari (sparsentan) is typically covered by Aetna CVS Health plans in Pennsylvania, but it requires prior authorization for all patients. The medication is usually placed on a high formulary tier due to its specialty status and cost (approximately $9,900-$10,038 per 30-day supply).

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing Aetna Provider Portal
Formulary Tier Specialty tier (highest copay) Member benefits summary
Step Therapy Must try ACE inhibitors/ARBs first Clinical documentation
Quantity Limits 1 tablet per day maximum FDA prescribing information
Site of Care CVS Specialty Pharmacy preferred Specialty pharmacy network
Age Limits 18 years or older FDA label indication

Prior Authorization Process

The PA process involves your nephrologist submitting detailed clinical documentation to Aetna CVS Health demonstrating medical necessity.

Step-by-Step: Fastest Path to Approval

  1. Nephrologist Reviews Requirements (Day 1)
    • Confirm biopsy-proven IgA nephropathy diagnosis
    • Document failed ACE inhibitor/ARB therapy
    • Verify current eGFR ≥30 mL/min/1.73m² and proteinuria levels
  2. REMS Enrollment (Days 1-3)
    • Complete prescriber and patient REMS enrollment forms
    • Schedule quarterly liver function tests
    • Submit to FILSPARI REMS program
  3. Gather Clinical Documentation (Days 2-5)
    • Kidney biopsy pathology report
    • Recent UPCR and eGFR lab results (within 60 days)
    • Chart notes documenting prior therapy failures
    • Treatment history and contraindications
  4. Submit Prior Authorization (Day 5-7)
    • Use Aetna provider portal or designated PA forms
    • Include all required clinical documentation
    • Request expedited review if clinically urgent
  5. Follow Up (Days 10-14)
    • Check PA status via provider portal
    • Respond promptly to requests for additional information
    • Consider peer-to-peer review if initial denial
  6. Specialty Pharmacy Coordination (Upon approval)
    • CVS Specialty will contact patient for enrollment
    • Verify insurance benefits and copay assistance options
    • Schedule medication delivery and clinical monitoring
  7. Monitor and Maintain (Ongoing)
    • Complete quarterly liver function tests
    • Submit renewal PA requests before expiration
    • Document clinical response for continued coverage

Timeline and Urgency

Standard Timeline

  • Initial PA decision: 30-45 days for commercial plans
  • Medicare Part D: Up to 72 hours for standard requests
  • Expedited reviews: 72 hours or less when medically urgent

When to Request Expedited Review

Request expedited processing if:

  • Patient has rapidly declining kidney function
  • Significant proteinuria with risk of progression
  • Current therapy causing serious adverse effects
  • Hospitalization risk without treatment

Clinical Criteria Requirements

Aetna CVS Health requires specific clinical documentation for Filspari approval:

Primary Requirements

  • Diagnosis: Biopsy-proven primary IgA nephropathy
  • Age: 18 years or older
  • Prescriber: Nephrologist (kidney specialist)
  • Kidney Function: eGFR ≥30 mL/min/1.73m²
  • Proteinuria: Persistent proteinuria (typically UPCR ≥1.5 g/g)

Step Therapy Requirements

  • Failed ACE Inhibitor or ARB: Minimum 3-month trial at maximally tolerated doses
  • Common acceptable options:
    • ACE inhibitors: lisinopril, enalapril, benazepril
    • ARBs: losartan, valsartan, irbesartan
  • Documentation of failure: Inadequate response, intolerance, or contraindications

REMS Compliance

  • Prescriber and patient enrollment in FILSPARI REMS program
  • Baseline liver function tests before first dose
  • Quarterly ALT/AST monitoring throughout treatment
  • Patient counseling documentation
Clinician Corner: Your medical necessity letter should include: (1) biopsy-confirmed IgA nephropathy diagnosis with pathology report, (2) current eGFR and UPCR values, (3) detailed history of ACE inhibitor/ARB trials with specific medications, doses, duration, and reasons for discontinuation, (4) risk stratification showing progression risk, and (5) treatment goals with Filspari therapy.

Cost Considerations

Insurance Coverage

  • Commercial plans: Typically specialty tier copay ($100-500+ per month)
  • Medicare Part D: Coverage varies by plan formulary
  • Medicaid: Prior authorization required; coverage varies by state

Financial Assistance Options

  • Travere Copay Support Program: May reduce copay to $0 for eligible commercially insured patients
  • CVS Specialty financial counseling: Available to help navigate assistance programs
  • Patient assistance programs: Income-based support for uninsured/underinsured patients

Contact CVS Specialty Pharmacy at enrollment to discuss all available financial assistance options.

Denials and Appeals in Pennsylvania

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing REMS enrollment Submit completed prescriber and patient REMS forms
Inadequate step therapy Provide detailed documentation of ACE inhibitor/ARB trials
Insufficient clinical documentation Include biopsy report, recent labs, nephrologist notes
Non-formulary status Request formulary exception with medical necessity letter
Quantity limit exceeded Justify dosing per FDA label and clinical guidelines

Pennsylvania Appeals Process

Internal Appeals (First Level)

  • Deadline: 180 days from denial notice (65 days for Medicare Part D)
  • Timeline: 30-45 days for decision
  • How to file: Aetna member portal, mail, or fax per denial letter instructions

External Review (Pennsylvania) Pennsylvania's Independent External Review Program offers strong consumer protections:

  • Deadline: 4 months after final internal denial
  • Success rate: Approximately 50% of appeals are overturned
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Filing: Online at pa.gov or by mail/fax
From Our Advocates: We've seen success when families compile a comprehensive appeal package including the nephrologist's detailed letter, published treatment guidelines for IgA nephropathy, and documentation showing Filspari is FDA-approved for the patient's specific condition. The key is addressing each reason for denial point by point with clinical evidence.

Renewal Requirements

Filspari prior authorizations typically require renewal every 6-12 months. For successful renewal:

Required Documentation

  • Clinical response: Stabilized or improved eGFR and proteinuria
  • Tolerability: No unacceptable adverse effects
  • Compliance: Completed quarterly liver function tests
  • Continued medical necessity: Ongoing risk of IgA nephropathy progression

Renewal Timeline

Submit renewal requests 30-45 days before current authorization expires to avoid treatment interruption.

CVS Specialty Pharmacy

Most Aetna plans require Filspari to be dispensed through CVS Specialty Pharmacy due to:

  • REMS program compliance monitoring
  • Specialized handling requirements
  • Clinical support services
  • Coordinated care management

What to Expect

  • Initial consultation with specialty pharmacist
  • Medication delivery coordination
  • Ongoing clinical monitoring support
  • Insurance and financial assistance coordination

Troubleshooting Common Issues

Portal or System Issues

  • Provider portal down: Call Aetna provider services for alternative submission methods
  • Missing forms: Contact CVS Caremark for current PA forms and requirements
  • Status updates: Allow 24-48 hours for system updates after submission

Documentation Issues

  • Incomplete biopsy reports: Request complete pathology report from performing institution
  • Missing lab values: Ensure UPCR and eGFR are from within 60 days of submission
  • Prior therapy documentation: Include medication names, doses, duration, and specific reasons for discontinuation

Frequently Asked Questions

How long does Aetna CVS Health PA take in Pennsylvania? Standard PA decisions take 30-45 days for commercial plans. Medicare Part D has shorter timelines (up to 72 hours). Expedited reviews are available when medically urgent.

What if Filspari is non-formulary on my plan? You can request a formulary exception by providing medical necessity documentation showing Filspari is clinically appropriate and preferred alternatives are not suitable.

Can I request an expedited appeal? Yes, if there's urgent medical need. Document why delay would jeopardize health and request expedited processing in your appeal submission.

Does step therapy apply if I failed ACE inhibitors outside Pennsylvania? Yes, prior therapy failures from any location count toward step therapy requirements. Provide complete documentation from all treating physicians.

What happens if I can't afford the copay? CVS Specialty can help you apply for manufacturer copay assistance, patient assistance programs, and foundation grants. Contact them at enrollment for financial counseling.

How often do I need liver function tests? Quarterly (every 3 months) ALT/AST monitoring is required throughout Filspari treatment as part of the REMS program.

When to Contact Pennsylvania Regulators

If you've exhausted internal appeals and need additional help, contact:

  • Pennsylvania Insurance Department: For external review requests and consumer assistance
  • Pennsylvania Health Law Project: Free legal assistance for complex appeals
  • Pennie Consumer Hotline: For marketplace plan issues

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. The platform identifies specific denial reasons and drafts point-by-point responses aligned with each payer's requirements, significantly improving approval rates for complex medications like Filspari.

For additional support with your Filspari appeal, Counterforce Health can help analyze your denial letter and create a comprehensive response that addresses Aetna's specific coverage criteria while incorporating the clinical evidence needed for approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current requirements with your insurance plan and healthcare providers. Consult with your nephrologist about the appropriateness of Filspari for your specific condition.

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