By Counterforce Health Team in Filspari (sparsentan) —

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

Answer Box: Getting Filspari Covered by Blue Cross Blue Shield in Virginia

To get Filspari (sparsentan) covered by Blue Cross Blue Shield in Virginia, you need: (1) confirmed IgA nephropathy diagnosis with UPCR ≥1.5 g/g, (2) REMS program enrollment, and (3) prior authorization showing 90+ days of optimized ACE/ARB therapy. Start by having your prescriber submit the PA request with baseline liver function tests and documentation of disease progression risk. If denied, Virginia law provides step therapy exceptions and external review through the State Corporation Commission within 120 days.

Table of Contents

  1. Why Virginia State Rules Matter
  2. Blue Cross Blue Shield Prior Authorization Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Virginia Step Therapy Protections
  5. Continuity of Care During Transitions
  6. Appeals Process and External Review
  7. Common Denial Reasons & Solutions
  8. Practical Scripts for Patients
  9. FAQ
  10. Sources & Further Reading

Why Virginia State Rules Matter

Virginia's insurance laws provide specific protections that can help you get Filspari covered, even when Blue Cross Blue Shield initially denies coverage. These state rules interact with your plan policies in several key ways:

Line-of-Business Differences: If you have a fully insured commercial plan through Blue Cross Blue Shield (Anthem) in Virginia, state laws fully apply. For self-funded employer plans (ERISA), federal protections remain but Virginia-specific rules may not apply—though you can still use them as persuasive arguments.

Virginia's healthcare landscape has improved significantly since Medicaid expansion in 2019, with the uninsured rate dropping to 6.4% in 2023. Anthem Blue Cross Blue Shield holds about 43% of Virginia's commercial insurance market, making understanding their specific policies crucial for patients seeking specialty drug coverage.

Note: Counterforce Health helps patients navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-based appeals that align with payer-specific criteria and state regulations.

Blue Cross Blue Shield Prior Authorization Requirements

Coverage Eligibility Criteria

Based on Blue Cross Blue Shield formulary policies, Filspari requires prior authorization with these criteria:

Patient Selection Requirements:

  • Age 18 years or older
  • Confirmed diagnosis of primary IgA nephropathy via kidney biopsy
  • UPCR ≥1.5 g/g indicating risk for rapid disease progression
  • Receipt of optimized supportive care for at least 90 days
  • Use of maximally tolerated ACE inhibitor or ARB for at least 90 days

Important Restrictions:

  • Cannot be used with ARBs, ERAs, aliskiren, or ACE inhibitors
  • Maximum dose: 400 mg per day
  • Initial authorization duration: 12 months
  • Quantity limits: 30 tablets per 30 days

Monitoring Requirements:

  • AST, ALT, and total bilirubin every 3 months
  • Pregnancy status monitoring (if applicable)

Step-by-Step: Fastest Path to Approval

1. REMS Program Enrollment (Prescriber)

Who: Your prescriber must complete first Documents: Prescriber Enrollment Form Submit: Online at FILSPARIREMS.com or fax 1-833-483-4736 Timeline: 1-2 business days for approval

2. Patient Enrollment and Labs

Who: Prescriber completes for patient Documents: Patient Start Form, REMS Patient Enrollment Form Required Labs: Baseline liver function tests (ALT, AST, total bilirubin) Submit: Via Travere TotalCare portal

3. Prior Authorization Submission

Who: Prescriber or clinic staff Documents: PA form, medical records, lab results, prior therapy documentation Submit: Through Blue Cross Blue Shield provider portal or fax Timeline: Standard determination within 15 days; urgent within 72 hours

4. Clinical Documentation

Required Elements:

  • ICD-10 diagnosis code for IgA nephropathy
  • Kidney biopsy results confirming primary IgAN
  • UPCR results ≥1.5 g/g
  • Documentation of 90+ days optimized ACE/ARB therapy
  • Blood pressure and cardiovascular risk management records

5. Monitor Response

Standard Timeline: 15 calendar days for non-urgent requests Expedited Timeline: 72 hours for urgent medical situations Follow-up: Contact Blue Cross Blue Shield if no response within stated timeframes

Virginia Step Therapy Protections

Virginia Code § 38.2-3407.9:05 provides mandatory step therapy exceptions that Blue Cross Blue Shield must honor for fully insured plans. You can request an override if:

Exception Criteria

  1. Contraindication: The required step drug is medically contraindicated
  2. Expected Ineffectiveness: Based on patient characteristics and drug properties
  3. Prior Trial and Failure: Patient previously tried the step drug with documented failure or adverse events
  4. Current Stability: Patient is stable on the requested drug under current or prior plan

Timeline Requirements

  • Standard Response: Within 72 hours of request
  • Urgent Situations: Within 24 hours for serious health risks
  • Plans must provide clear, accessible exception process on their website

For IgA Nephropathy Patients: Emphasize that you represent an "atypical patient population" where standard step therapy may not reflect appropriate evidence-based care for this rare kidney disease.

Continuity of Care During Transitions

Virginia provides protections when changing plans or facing formulary changes:

Transition Protections

  • Existing Authorizations: New plans should honor prior authorizations for at least 90 days
  • Transition Fills: Short-term continuation while new authorization is processed
  • Stable Therapy Protection: Patients on chronic, stable therapy receive stronger protection

Anthem BCBS Virginia Updates

As of October 2025, Anthem has aligned Medicaid prior authorization requirements with DMAS to reduce "interrupted or delayed care." This policy direction influences commercial plan practices as well.

Actionable Steps:

  1. Request continuation under "ongoing specialty therapy for chronic condition"
  2. Have prescriber document clinical risk of therapy interruption
  3. Cite Virginia's policy protecting active courses of treatment during transitions

Appeals Process and External Review

Internal Appeals

Timeline: Must be filed within timeframe specified in denial letter (typically 60-180 days) Process: Submit through Blue Cross Blue Shield member portal or by mail/fax Required: Copy of denial letter, medical records, prescriber letter supporting medical necessity

Virginia External Review

Managed by the State Corporation Commission Bureau of Insurance under Va. Code § 38.2-3561-3562:

Eligibility Requirements:

  • Must complete internal appeals first
  • File within 120 days of final denial notice
  • Denial must be based on medical necessity or clinical criteria

Timeline:

  • Standard Review: Decision within 45 days
  • Expedited Review: Decision within 72 hours for urgent cases
  • Filing Deadline: 120 days from denial notice

How to File: Submit Form 216-A (External Review Request) to Virginia Bureau of Insurance

From our advocates: We've seen patients successfully overturn Filspari denials by documenting that standard IgA nephropathy treatments failed to control proteinuria, making the patient eligible for this first-in-class therapy. The key is showing you meet FDA-approved criteria and that denial contradicts established treatment guidelines.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Missing REMS enrollment Complete enrollment first REMS confirmation, quarterly LFTs
No documented IgAN Provide biopsy results Pathology report, ICD-10 codes
Insufficient prior therapy Document 90+ days ACE/ARB Prescription records, clinic notes
Step therapy required Request exception Prior failure documentation
Quantity limits exceeded Justify medical necessity Dosing rationale from prescriber

Practical Scripts for Patients

Calling Blue Cross Blue Shield Member Services

"Hello, I'm calling about prior authorization for Filspari, which my doctor prescribed for IgA nephropathy. I need to understand your coverage requirements and appeals process. Can you tell me:

  • What specific documentation is needed for approval?
  • What is your standard timeline for PA decisions?
  • How do I request an expedited review if needed?
  • What step therapy requirements apply, and how do I request an exception under Virginia law?"

Requesting Expedited Appeal

"I'm requesting an expedited appeal for my Filspari denial. My nephrologist states that delaying this FDA-approved treatment for IgA nephropathy could lead to irreversible kidney damage. Under Virginia Code § 38.2-3562, I'm eligible for expedited external review if this denial seriously jeopardizes my health."

FAQ

How long does Blue Cross Blue Shield prior authorization take in Virginia? Standard PA decisions: 15 calendar days. Urgent requests: 72 hours. Virginia law requires step therapy exception responses within 72 hours (24 hours for urgent situations).

What if Filspari is non-formulary on my Blue Cross Blue Shield plan? Request a formulary exception based on medical necessity. Document that formulary alternatives are contraindicated, ineffective, or previously failed. Virginia's step therapy law supports exceptions for atypical patient populations.

Can I request an expedited appeal in Virginia? Yes, for urgent medical situations where delays could seriously jeopardize health. Submit expedited external review request to Virginia Bureau of Insurance with physician certification of urgency.

Does Virginia step therapy law apply to self-funded employer plans? Generally no, but you can use Virginia's criteria as persuasive arguments and reference federal protections under ERISA and the ACA appeals process.

What monitoring is required for Filspari coverage? Quarterly liver function tests (ALT, AST, total bilirubin) and pregnancy monitoring if applicable. REMS enrollment is mandatory for all prescribers and patients.

How do I file an external review in Virginia? Complete internal appeals first, then submit Form 216-A to Virginia Bureau of Insurance within 120 days of final denial. Standard reviews take 45 days; expedited reviews take 72 hours.

Sources & Further Reading

Disclaimer: This information is educational and not medical advice. Coverage decisions depend on your specific plan benefits and clinical circumstances. For personalized guidance, consult your healthcare provider and contact your insurance plan directly. Counterforce Health provides specialized support for navigating complex prior authorization requirements and appeals processes.

Need Help? Virginia consumers can contact the Bureau of Insurance at 1-877-310-6560 for assistance with insurance complaints and external review questions.

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