By Counterforce Health Team in Filspari (sparsentan) —

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

Answer Box: Fast Track to Filspari Coverage in Texas

To get Filspari (sparsentan) covered by Aetna CVS Health in Texas: Your nephrologist must submit a prior authorization showing biopsy-confirmed primary IgA nephropathy, UPCR ≥0.8 g/g, and 3+ months of failed ACE/ARB therapy. Complete REMS enrollment at filsparirems.com first. If denied, you have 180 days to appeal internally, then can request binding external review through Texas Department of Insurance. Start today: Verify REMS status and gather your kidney biopsy report.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timeline Expectations
  7. If You Need to Provide More Information
  8. If Your Request is Denied
  9. Renewal and Re-Authorization
  10. Common Denial Reasons and Solutions
  11. Appeals Process for Texas
  12. Costs and Patient Assistance
  13. Frequently Asked Questions

What This Guide Covers

This guide helps patients with IgA nephropathy (IgAN) and their healthcare teams navigate Aetna CVS Health's prior authorization process for Filspari (sparsentan) in Texas. We'll walk through every step from initial submission to appeals, including state-specific timelines and forms.

Who this helps: Patients with biopsy-confirmed primary IgA nephropathy whose doctors recommend Filspari, along with nephrologists, clinic staff, and caregivers managing the approval process.

Expected outcome: With proper documentation, most medically appropriate Filspari requests get approved within 15-45 business days. If denied, Texas law provides strong appeal rights including binding external review.

Before You Start: Verify Your Coverage

Check Your Plan Type

First, confirm whether you have an Aetna commercial plan, Medicare, or Medicaid coverage, as requirements differ:

  • Commercial plans: Follow Texas state-regulated appeal timelines (180 days for internal appeals)
  • Medicare: Federal appeal rules apply (60 days for internal appeals)
  • Medicaid: Texas Medicaid fair hearing process available

Verify Filspari's Formulary Status

Filspari appears on most Aetna formularies but often requires prior authorization:

Plan Type Typical Status Coverage Notes
Aetna Standard Preferred Specialty (PSP) PA required
Advanced Control Non-formulary Exception needed
Medicaid Covered with PA Step therapy applies

Action step: Call the member services number on your insurance card or check your plan's drug formulary online to confirm Filspari's status.

Confirm Network Status

Filspari must be dispensed through CVS Specialty Pharmacy as part of Aetna's network. Your nephrologist should be in-network for the smoothest prior authorization process.

Gather Required Documentation

Essential Clinical Documents

For your nephrologist to collect:

  • Kidney biopsy report confirming primary IgA nephropathy (pathology showing IgA-dominant deposits)
  • Recent labs (within 60 days): UPCR ≥0.8 g/g or 24-hour proteinuria ≥1 g/day
  • eGFR documentation showing current kidney function
  • Blood pressure logs demonstrating control on current therapy
  • Medication history showing 3+ months of maximally tolerated ACE inhibitor or ARB therapy
  • Documentation of ACE/ARB failure, intolerance, or contraindications

REMS Program Requirements

Filspari requires enrollment in a Risk Evaluation and Mitigation Strategy (REMS) program due to hepatotoxicity risk:

  1. Prescriber enrollment: Your nephrologist must complete training at filsparirems.com
  2. Patient enrollment: Complete the FILSPARI REMS Patient Enrollment Form
  3. Monitoring plan: Quarterly liver function tests (ALT/AST every 3 months)
Note: REMS requirements were updated in August 2025, reducing monitoring from monthly to quarterly LFTs.

Administrative Documents

  • Insurance card (front and back)
  • Photo ID
  • Prior authorization form (available through Aetna provider portal)
  • Medical necessity letter from your nephrologist

Submit Your Prior Authorization Request

Submission Methods

Primary option: Your nephrologist's office submits through:

  • Aetna provider portal (Availity)
  • Fax: 1-724-741-4953
  • Phone: 1-866-235-5660

Clean Request Packet Checklist

Ensure your nephrologist includes:

✓ Completed prior authorization form
✓ Medical necessity letter citing FDA indication for IgAN
✓ Kidney biopsy report
✓ Lab results (UPCR, eGFR, LFTs)
✓ ACE/ARB trial documentation
✓ REMS enrollment confirmation
✓ ICD-10 diagnosis code (N02.8 for primary IgAN)

Specialty Pharmacy Coordination

Since Filspari requires specialty pharmacy dispensing, your doctor's office should coordinate with:

  • CVS Specialty Pharmacy (Aetna's preferred network)
  • Travere Total Care (manufacturer's patient support hub): 1-833-345-7727

Follow-Up and Tracking

When to Call

  • Day 3: Confirm Aetna received your request
  • Day 10: Check processing status
  • Day 20: Inquire about timeline if no decision

Sample Call Script

"Hi, I'm calling to check the status of a prior authorization request for Filspari submitted for [patient name], member ID [number]. The request was submitted on [date]. Can you provide an update on the review status and expected decision timeline?"

Document: Request reference numbers, representative names, and callback information.

Typical Timeline Expectations

Standard Review Process

Review Type Texas Timeline Notes
Standard PA 15-45 business days May extend for specialty review
Expedited PA 36-72 hours Available if delay jeopardizes health
Appeal decision 30-45 days Internal review process
External review 20 days standard, 8 days expedited Binding decision

What Speeds Decisions

  • Complete documentation on first submission
  • In-network nephrologist
  • Clear medical necessity rationale
  • REMS enrollment already completed

What Slows Decisions

  • Missing lab values or biopsy report
  • Incomplete ACE/ARB trial documentation
  • REMS enrollment delays
  • Need for peer-to-peer review

If You Need to Provide More Information

Common Information Requests

Clinical clarification:

  • Updated lab values
  • Detailed ACE/ARB failure documentation
  • Progression risk assessment

Administrative details:

  • REMS compliance verification
  • Specialty pharmacy confirmation
  • Dosing rationale

Handling Medical Necessity Questions

Your nephrologist should emphasize:

  • FDA approval for IgAN with risk of progression
  • Evidence of proteinuria despite optimal standard therapy
  • Patient's specific clinical circumstances requiring Filspari

Supporting literature: Reference the FDA label and recent IgAN treatment guidelines.

If Your Request is Denied

Understanding Denial Codes

Common Denial What It Means Next Steps
"Not medically necessary" Clinical criteria not met Peer-to-peer review
"Non-formulary" Drug not on preferred list Formulary exception
"Step therapy" Must try alternatives first Document failures/intolerance
"REMS non-compliance" Monitoring requirements not met Complete enrollment

First-Level Response Options

  1. Peer-to-peer review: Your nephrologist can request a call with Aetna's medical director
  2. Resubmission: Address specific denial reasons with additional documentation
  3. Expedited appeal: If delay would jeopardize your health
Tip: Request the specific policy or criteria Aetna used to make the denial decision.

Appeals Process for Texas

Internal Appeal (Required First Step)

Filing deadline: 180 calendar days from denial notice
How to file:

  • Online: Aetna member portal
  • Phone: 1-866-235-5660
  • Fax: 1-724-741-4953
  • Mail: Address provided in denial letter

Required documents:

  • Appeal form or written request
  • Copy of denial letter
  • Updated medical necessity letter
  • Any new supporting documentation

Decision timeline:

  • Standard: 45 business days
  • Expedited: 36-72 hours (if health jeopardized)

External Review (After Internal Denial)

Eligibility: Available for medical necessity denials
Filing deadline: 4 months from final internal denial
Process: Texas Department of Insurance coordinates Independent Review Organization (IRO)
Cost: Paid by Aetna
Decision: Binding on Aetna if approved

Timeline:

  • Standard: 20 days
  • Expedited: 8 days

Contact for help: Texas Department of Insurance: 1-800-252-3439

Costs and Patient Assistance

List Price Information

Filspari's list price is approximately $9,900-$10,038 per 30-day supply, making patient assistance crucial for most families.

Available Support Programs

Travere Patient Access Program:

  • Copay assistance for eligible commercially insured patients
  • Free drug program for qualifying uninsured patients
  • Contact: 1-833-345-7727

Foundation Resources:

  • National Kidney Foundation patient navigation
  • IgA Nephropathy Foundation support groups
  • Local Texas kidney disease organizations

Texas-Specific Programs:

  • Texas Medicaid (for income ≤138% FPL in participating counties)
  • State pharmaceutical assistance programs

Frequently Asked Questions

Q: How long does Aetna prior authorization take in Texas?
A: Standard reviews typically take 15-45 business days. Expedited reviews are available within 36-72 hours if delay would jeopardize your health.

Q: What if Filspari is non-formulary on my plan?
A: You can request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate for your condition.

Q: Can I request an expedited appeal?
A: Yes, if delaying treatment would seriously jeopardize your health or ability to regain maximum function. Document the urgency clearly.

Q: Does step therapy apply if I failed ACE/ARB therapy outside Texas?
A: Yes, documented failures from any location are typically accepted. Provide complete medical records showing the trial and failure/intolerance.

Q: What happens if I miss the appeal deadline?
A: Texas allows up to 180 days for internal appeals. If you miss this deadline, you may need to submit a new prior authorization request.

Q: Can my doctor submit a new PA while an appeal is pending?
A: Yes, this strategy can sometimes result in faster approval, especially if new clinical information becomes available.

Renewal and Re-Authorization

When to Start Renewal Process

Begin 90 days before your current authorization expires to avoid treatment interruptions.

Required Renewal Documentation

  • Updated lab values showing response (≥20-30% UPCR reduction preferred)
  • Continued REMS compliance with quarterly LFTs
  • Nephrologist note documenting continued medical necessity
  • Any changes in clinical status

Annual Review Timeline

Most Filspari authorizations are approved for 12 months, requiring annual renewal with response documentation.

Printable Checklist

Before Starting: □ Verify insurance coverage and formulary status
□ Confirm nephrologist is in-network
□ Complete REMS enrollment

Documentation to Gather: □ Kidney biopsy report
□ Recent labs (UPCR, eGFR, LFTs)
□ ACE/ARB trial history
□ Blood pressure logs

Submission: □ Submit complete PA packet
□ Coordinate with CVS Specialty Pharmacy
□ Track reference numbers

Follow-Up: □ Call Day 3, 10, and 20
□ Prepare for potential peer-to-peer
□ Know appeal deadlines

Counterforce Health specializes in turning insurance denials into successful appeals for patients needing specialty medications like Filspari. Our platform helps identify denial reasons and creates evidence-backed appeals aligned with each payer's specific requirements, saving time for patients, clinicians, and specialty pharmacies while improving approval rates.

When navigating complex prior authorizations, having expert support can make the difference between approval and denial. Counterforce Health provides targeted assistance that turns insurance obstacles into clear pathways to treatment.

From our advocates: We've seen Filspari approvals improve significantly when the initial submission includes clear documentation of both ACE/ARB trial duration and specific reasons for failure (e.g., persistent proteinuria despite maximum tolerated doses for 4+ months, or documented hyperkalemia requiring dose reduction). This level of detail helps medical reviewers understand why standard therapy was inadequate.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical advice. Coverage decisions depend on individual circumstances, plan terms, and clinical factors. Always consult with your healthcare provider about treatment decisions and verify current coverage details with your insurance plan. For personalized assistance with appeals, contact qualified patient advocacy organizations or legal counsel.

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