By Counterforce Health Team in Filspari (sparsentan) —

How to Get Filspari (sparsentan) Covered by Blue Cross Blue Shield in Pennsylvania: Prior Authorization Guide and Appeals Process

Quick Answer: Getting Filspari Covered by Blue Cross Blue Shield in Pennsylvania

Filspari (sparsentan) requires prior authorization from Blue Cross Blue Shield plans in Pennsylvania. You'll need: confirmed IgA nephropathy diagnosis via kidney biopsy, documented REMS enrollment, quarterly liver function tests, and evidence of failed ACE inhibitor/ARB therapy. If denied, Pennsylvania's new external review program overturns ~50% of appeals. Start by having your nephrologist submit a complete prior authorization packet through your plan's provider portal.

First step today: Contact your Blue Cross Blue Shield plan at the number on your insurance card to request Filspari prior authorization forms and criteria.

Table of Contents

  1. Understanding Filspari Coverage Requirements
  2. Blue Cross Blue Shield Plans in Pennsylvania
  3. Pre-Authorization Preparation
  4. Submitting Your Prior Authorization
  5. Common Denial Reasons and Solutions
  6. Appeals Process in Pennsylvania
  7. Pennsylvania's External Review Program
  8. Cost and Financial Support Options
  9. Frequently Asked Questions

Understanding Filspari Coverage Requirements

Filspari (sparsentan) is a first-in-class dual endothelin type-A/angiotensin II type-1 receptor antagonist approved for adults with primary IgA nephropathy at risk for disease progression. With a list price of approximately $9,900-$10,038 per 30-day supply, this specialty medication requires careful documentation for insurance approval.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing Your plan's provider portal or formulary
REMS Enrollment Both prescriber and patient must enroll FILSPARI REMS website
Specialty Pharmacy Limited distribution through certified pharmacies Plan's specialty pharmacy network
Quarterly Monitoring Liver function tests every 3 months Prescriber's office coordination
Diagnosis Documentation Biopsy-confirmed IgA nephropathy Nephrology records

Blue Cross Blue Shield Plans in Pennsylvania

Pennsylvania has multiple Blue Cross Blue Shield plans, with regional variations in coverage policies:

  • Highmark Blue Shield (western Pennsylvania) - approximately 31% of commercial market
  • Independence Blue Cross (Philadelphia region)
  • Blue Cross of Northeastern Pennsylvania

Each plan maintains its own formulary and prior authorization criteria, though they share common elements. For specific requirements, contact your plan directly:

  • Highmark Provider Services: 1-844-325-6251 (8 a.m. – 5 p.m., Monday-Friday)
  • Independence Blue Cross Authorizations: 1-800-ASK-BLUE
Note: The research findings indicate that specific Filspari prior authorization criteria for Pennsylvania Blue Cross Blue Shield plans are not publicly available. Contact your plan directly for current requirements.

Pre-Authorization Preparation

Essential Clinical Documentation

Your nephrologist will need to compile comprehensive documentation before submitting a prior authorization request:

1. Confirmed IgA Nephropathy Diagnosis

  • Kidney biopsy report showing IgA deposits in glomeruli
  • ICD-10 codes: N02.8 or N05.8
  • Pathology report with immunofluorescence findings

2. Current Clinical Parameters

  • Urine protein-to-creatinine ratio (UPCR) ≥0.8 g/g or 24-hour urine ≥1 g/day
  • Estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73m²
  • Recent liver function tests (ALT/AST)

3. Prior Therapy Documentation

  • Minimum 12-week trial of optimized ACE inhibitor or ARB therapy
  • Specific medications, doses, and documented failure or intolerance
  • Blood pressure management records

4. REMS Program Enrollment

  • Prescriber enrollment in FILSPARI REMS
  • Patient enrollment form completion
  • Documented liver function assessment

Clinician Corner: Medical Necessity Letter Checklist

When your nephrologist writes the medical necessity letter, ensure it includes:

  • Problem Statement: Clear diagnosis of IgA nephropathy with progression risk
  • Prior Treatments: Detailed history of ACE inhibitor/ARB trials with specific outcomes
  • Clinical Rationale: Why Filspari is appropriate based on FDA labeling and clinical guidelines
  • Monitoring Plan: Commitment to quarterly liver function testing and REMS compliance
  • Treatment Goals: Expected outcomes for proteinuria reduction and kidney function preservation

Submitting Your Prior Authorization

Step-by-Step Submission Process

1. Gather Required Documents (Patient/Family)

  • Insurance card with member ID
  • Complete medical records from nephrology visits
  • Lab results (kidney function, liver function, urinalysis)
  • List of all previously tried medications

2. REMS Enrollment (Prescriber and Patient)

  • Complete prescriber enrollment at FILSPARI REMS
  • Submit patient enrollment form with baseline labs
  • Timeline: Allow 1-2 business days for processing

3. Prior Authorization Submission (Prescriber's Office)

  • Submit through plan's electronic portal (Availity for Highmark, PEAR PM for Independence)
  • Include all clinical documentation and REMS enrollment confirmation
  • Timeline: Plans typically respond within 72 hours to 5 business days

4. Specialty Pharmacy Coordination

  • Independence Blue Cross uses Optum Specialty Pharmacy
  • Highmark contracts with various specialty pharmacy networks
  • Pharmacy will coordinate with REMS program and insurance authorization

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Missing REMS enrollment Complete enrollment before resubmission REMS confirmation numbers for prescriber and patient
Insufficient prior therapy Document ACE inhibitor/ARB trial details Pharmacy records, clinic notes showing specific medications, doses, duration, and outcomes
Lab requirements not met Submit current kidney and liver function tests Recent UPCR, eGFR, ALT/AST results within 30 days
Non-formulary status Request formulary exception Medical necessity letter explaining why alternatives are inappropriate
Quantity limits exceeded Justify dosing based on FDA labeling FDA prescribing information highlighting approved dosing

Appeals Process in Pennsylvania

If your initial prior authorization is denied, Pennsylvania offers a structured appeals process with multiple levels:

Internal Appeals (Required First Step)

Timeline: 180 days from denial for commercial plans How to Submit:

  • Online through your plan's member portal
  • Written appeal to address on denial letter
  • Phone: Use authorization number from your insurance card

Required Documents:

  • Original denial letter
  • Additional medical records addressing denial reasons
  • Updated lab results if available
  • Prescriber letter responding to specific denial points

Peer-to-Peer Review

Many Blue Cross Blue Shield plans offer peer-to-peer reviews where your nephrologist can speak directly with the plan's medical director.

Script for Clinic Staff: "I'm calling to request a peer-to-peer review for [patient name], member ID [number]. We received a denial for Filspari and would like our nephrologist to discuss the medical necessity with your reviewing physician."

Pennsylvania's External Review Program

Pennsylvania launched its Independent External Review Program in January 2024, providing a powerful tool for overturning insurance denials.

Key Statistics

  • Success Rate: Approximately 50% of appeals overturned in first year
  • Volume: 517 external appeals filed in 2024
  • Patient Wins: 259 cases resulted in coverage approval

External Review Process

Eligibility: You must first complete your plan's internal appeal process and receive a Final Adverse Benefit Determination letter.

Timeline:

  • 4 months to request external review after final internal denial
  • 45 days for standard review decision
  • 72 hours for expedited review (urgent health situations)

How to Submit:

  • Online: pa.gov/reviewmyclaim
  • Phone: 1-877-881-6388
  • Mail/Fax: Forms available on Pennsylvania Insurance Department website

Cost: Free to patients

From Our Advocates: We've seen strong success with external reviews when families submit comprehensive medical evidence within the 15-day window after assignment. Include recent research supporting the medication's effectiveness and any updated clinical information that wasn't available during the internal appeal.

What Makes External Reviews Successful

Strong Documentation Package:

  • Complete medical timeline showing disease progression
  • Peer-reviewed studies supporting Filspari's effectiveness in IgA nephropathy
  • Evidence that patient meets FDA-approved criteria
  • Documentation of contraindications to alternative treatments

Independent Review Organizations (IROs) assigned by Pennsylvania consist of physicians who review cases based on medical necessity, not cost considerations.

Cost and Financial Support Options

Manufacturer Support Programs

Travere Total Care

  • Patient support program offering copay assistance
  • Coverage investigation and prior authorization support
  • Contact: Information available through prescriber or Filspari HCP website

Additional Financial Resources

Patient Assistance Foundations

  • Chronic Disease Fund
  • HealthWell Foundation
  • Patient Access Network Foundation

Pennsylvania-Specific Resources

  • Pennsylvania Insurance Department Consumer Services: 1-877-881-6388
  • Pennsylvania Health Law Project: Free assistance for low-income individuals

When to Escalate

Contact Pennsylvania regulators if you encounter:

  • Delays beyond published timelines
  • Requests for inappropriate documentation
  • Denial of expedited review for urgent situations

Pennsylvania Insurance Department

  • Consumer Services Bureau: 1-877-881-6388
  • Website: pa.gov
  • File complaints online for unresolved coverage disputes

Frequently Asked Questions

Q: How long does Blue Cross Blue Shield prior authorization take in Pennsylvania? A: Most plans respond within 72 hours to 5 business days. Expedited reviews for urgent situations must be completed within 72 hours.

Q: What if Filspari is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Your prescriber must demonstrate why formulary alternatives are inappropriate.

Q: Can I request an expedited appeal if my kidney function is declining? A: Yes. If your health is at serious risk, request expedited internal and external reviews. Provide documentation of rapid disease progression.

Q: Does step therapy apply if I've tried ACE inhibitors outside Pennsylvania? A: Yes. Documentation of prior therapy trials from any location should satisfy step therapy requirements if properly documented.

Q: What happens if I'm approved but later denied refills? A: Ongoing approvals require continued REMS compliance and quarterly monitoring. Ensure your prescriber submits updated lab results every three months.

Q: How does Pennsylvania's external review compare to other states? A: Pennsylvania's 50% overturn rate is higher than many states. The program is new (launched 2024) and appears more patient-friendly than federal external review processes.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals. The platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes for specialty medications like Filspari.

For complex cases involving multiple denials or urgent medical situations, Counterforce Health can help craft appeals that address specific payer requirements and incorporate the right medical evidence to maximize approval chances.

Sources and Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your prescriber's office for prior authorization submissions. For specific coverage questions, contact your insurance plan directly. For assistance with the appeals process in Pennsylvania, contact the Insurance Department's Consumer Services Bureau at 1-877-881-6388.

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