By Counterforce Health Team in Filspari (sparsentan) —

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

Quick Answer: Getting Filspari (sparsentan) Covered by Aetna (CVS Health) in Virginia

Eligibility: Adults with biopsy-confirmed primary IgA nephropathy, proteinuria ≥1g/day, and failed ACE/ARB therapy. Fastest path: Have your nephrologist submit prior authorization with REMS enrollment, quarterly LFT plan, and step therapy documentation. Start today: Call Aetna member services to confirm formulary status and request PA forms. If denied, Virginia's external review process through the State Corporation Commission provides binding decisions within 45 days (72 hours for urgent cases).

Table of Contents

  1. Why Virginia State Rules Matter
  2. Aetna (CVS Health) Prior Authorization Requirements
  3. Step Therapy Protections in Virginia
  4. Appeals Timeline and Process
  5. Virginia External Review Process
  6. Common Denial Reasons and Solutions
  7. Patient Action Scripts
  8. Cost Assistance Programs
  9. When to Contact Virginia Regulators
  10. Frequently Asked Questions

Why Virginia State Rules Matter

Virginia's insurance laws provide crucial protections for patients seeking coverage of specialty medications like Filspari (sparsentan). The state's step therapy override statute (§ 38.2-3407.9:05) requires insurers to grant exceptions within 72 hours when medical criteria are met, while the external review process through the State Corporation Commission offers binding decisions that can overturn wrongful denials.

These protections apply to commercial Aetna (CVS Health) plans issued in Virginia, though self-funded employer plans may have different appeal rights. Virginia's uninsured rate dropped to a historic low of 6.4% in 2023 after Medicaid expansion, meaning more patients have access to these coverage protections.

Note: Virginia law mandates that step therapy exceptions must be granted if you've previously failed the required drug or if it's contraindicated—key leverage points for Filspari appeals.

Aetna (CVS Health) Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Documentation Needed Timeline
Diagnosis Biopsy-confirmed primary IgA nephropathy Kidney biopsy report Before PA submission
Proteinuria UPCR ≥0.8 g/g or proteinuria ≥1 g/day Recent lab results (within 60 days) With PA request
Step Therapy Failed ACE/ARB therapy for ≥3 months Treatment history, intolerance documentation Required
REMS Enrollment Provider and patient enrolled in safety program REMS certification Before prescribing
Specialist Nephrologist prescriber preferred Provider credentials verification With PA
LFT Monitoring Quarterly liver function tests Baseline and ongoing LFT plan Throughout treatment

Source: Aetna Medicaid Policy

REMS Program Requirements

The FDA's REMS program for Filspari was updated in 2024 to require liver function tests every 3 months (reduced from monthly). Both prescribers and patients must enroll before therapy begins. This is often a denial point if not completed properly.

Key REMS Documentation:

  • Prescriber REMS enrollment confirmation
  • Patient REMS enrollment and education completion
  • Baseline ALT, AST, and total bilirubin results
  • Plan for quarterly LFT monitoring throughout treatment

Step Therapy Protections in Virginia

Virginia's step therapy law provides four pathways to override requirements, particularly relevant for Filspari given its position after ACE/ARB therapy:

Medical Exception Criteria

Automatic approval required if:

  1. Contraindication: ACE/ARB caused hyperkalemia, angioedema, or acute kidney injury
  2. Prior failure: Patient tried maximally tolerated ACE/ARB for ≥3 months without adequate proteinuria reduction
  3. Ineffectiveness: Based on patient's clinical profile, ACE/ARB unlikely to work
  4. Stable therapy: Patient currently stable on Filspari under prior coverage

Documentation That Works

Clinician Corner: When requesting step therapy exceptions, include specific dates of ACE/ARB therapy, documented side effects or lack of efficacy, and current proteinuria levels. Virginia law requires a response within 72 hours.

Essential elements for your nephrologist to include:

  • Specific ACE inhibitor or ARB tried, dosage, and duration
  • Reason for discontinuation (adverse event, lack of efficacy, intolerance)
  • Current UPCR or 24-hour urine protein levels
  • eGFR trends showing progressive kidney function decline

Appeals Timeline and Process

Internal Appeals with Aetna (CVS Health)

Standard Appeals:

  • File within: 180 days of denial notice
  • Decision timeline: 30-45 days for standard review
  • Submit to: Aetna member/provider portal or appeals fax line

Expedited Appeals:

  • Criteria: Delay could seriously jeopardize health
  • Timeline: ≤72 hours for decision
  • Required: Physician certification of urgency

Required Documentation

  • Original denial letter
  • Complete medical records supporting necessity
  • Step therapy failure documentation
  • REMS enrollment confirmation
  • Nephrologist's detailed medical necessity letter
From Our Advocates: We've seen Filspari denials overturned when appeals included specific proteinuria reduction targets and cited the drug's FDA approval for patients "at risk for disease progression." The key is connecting your clinical picture to the exact FDA indication language.

Virginia External Review Process

If Aetna (CVS Health) upholds their denial, Virginia's external review provides a final avenue for coverage. This process is overseen by the State Corporation Commission and offers binding decisions.

Step-by-Step External Review

  1. Confirm Eligibility: Must complete Aetna's internal appeals first
  2. File Form 216-A: External Review Request Form within 120 days
  3. Submit Documentation: Include denial letters, medical records, and insurance card copy
  4. Await Assignment: SCC assigns to independent review organization (IRO)
  5. Provide Additional Info: 5 business days to submit extra documentation
  6. Receive Decision: 45 days for standard, 72 hours for expedited

Mailing Address: Bureau of Insurance – External Review
P.O. Box 1157
Richmond, VA 23218

Expedited Review Criteria

For urgent Filspari cases, expedited external review may be appropriate if:

  • Rapidly declining kidney function (eGFR dropping >5 mL/min/1.73m² per year)
  • Severe proteinuria (>3.5 g/day) with progressive symptoms
  • Risk of irreversible kidney damage without prompt treatment

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Key Documentation
Missing REMS enrollment Complete enrollment before resubmission REMS confirmation certificates
Inadequate step therapy Document ACE/ARB trial duration and failure Treatment timeline, side effects, lab trends
"Not medically necessary" Cite FDA label and kidney disease progression risk Biopsy results, proteinuria levels, eGFR decline
Quantity limits exceeded Request exception based on FDA-approved dosing Prescriber attestation of appropriate dosing
Non-formulary status Request formulary exception with medical necessity Comparative effectiveness documentation

Source: Analysis of Aetna formulary guidelines

Patient Action Scripts

Calling Aetna Member Services

"I'm calling about prior authorization for Filspari, generic name sparsentan, for IgA nephropathy. My doctor says it's medically necessary because I've failed ACE inhibitor therapy and meet the FDA criteria. Can you tell me the current formulary status and connect me to utilization management to discuss the denial?"

Requesting Peer-to-Peer Review

"My nephrologist would like to request a peer-to-peer review for the Filspari denial. The patient meets all FDA criteria including biopsy-confirmed IgA nephropathy and proteinuria over 1 gram per day. When can we schedule this review with one of your nephrology consultants?"

Cost Assistance Programs

Manufacturer Support:

Foundation Resources:

  • National Kidney Foundation patient assistance programs
  • IgA Nephropathy Foundation insurance navigation support
  • Virginia free clinic network for uninsured patients

State Programs: Virginia's Medicaid expansion covers adults up to 138% of federal poverty level, potentially providing coverage for Filspari through managed care plans.

When to Contact Virginia Regulators

State Corporation Commission Bureau of Insurance

Contact when:

  • Aetna fails to respond to appeals within required timeframes
  • Step therapy exception denied without valid medical reason
  • External review eligibility questions
  • Suspected violations of Virginia insurance law

Contact Information: Phone: (804) 371-9733
Website: scc.virginia.gov/boi
Consumer Services: 1-877-310-6560

Virginia Managed Care Ombudsman

For Medicaid managed care plans, the Virginia Managed Care Ombudsman provides free assistance with:

  • Understanding appeal rights
  • Preparing appeal documentation
  • Escalating unresolved denials
  • Navigating REMS requirements

Frequently Asked Questions

How long does Aetna (CVS Health) prior authorization take in Virginia? Standard PA decisions are typically made within 15 business days. Expedited reviews for urgent cases must be completed within 72 hours per Virginia law.

What if Filspari is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating medical necessity and providing evidence that formulary alternatives are inappropriate or have failed.

Can I request expedited appeal if my kidney function is declining? Yes, if your nephrologist certifies that delay could seriously jeopardize your health, Virginia law requires expedited appeals to be decided within 72 hours.

Does Virginia step therapy protection apply if I failed ACE/ARB therapy in another state? Yes, Virginia law recognizes prior therapy failures regardless of where they occurred, as long as you have documentation of the trial and reason for discontinuation.

What happens if the external review upholds Aetna's denial? The external review decision is final and binding. However, you retain rights to pursue other legal remedies and may reapply if your clinical condition changes significantly.

Are there income limits for Travere's patient assistance program? The manufacturer's program has income-based eligibility criteria. Patients with household incomes up to 400% of federal poverty level may qualify for assistance.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create evidence-backed appeals that meet payer-specific requirements, including Virginia's external review process and Aetna's utilization management criteria.

For complex cases like Filspari coverage, Counterforce Health provides targeted support that addresses specific denial reasons, incorporates REMS requirements, and leverages Virginia's patient protection laws to maximize approval chances.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For official Virginia insurance regulations and consumer assistance, contact the State Corporation Commission Bureau of Insurance.

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