By Counterforce Health Team in Filspari (sparsentan) —

How to Get Filspari (Sparsentan) Covered by Blue Cross Blue Shield in Washington: 2025 Forms, Appeals & Contacts

Answer Box: Getting Filspari Covered in Washington

Filspari (sparsentan) requires prior authorization and REMS program enrollment for Blue Cross Blue Shield coverage in Washington. Your fastest path: (1) Enroll prescriber and patient in the Filspari REMS program, (2) Submit the PA form via your plan's provider portal (Availity for Premera) with complete clinical documentation, (3) If denied, file an internal appeal within 180 days, then request external review through Washington's Independent Review Organization system.

Start today: Call your Blue Cross plan's member services number (on your card) to confirm your specific PA form and REMS requirements.

Table of Contents

  1. Verify Your Blue Cross Plan
  2. Prior Authorization Forms & Requirements
  3. REMS Program Enrollment
  4. Submission Portals & Methods
  5. Specialty Pharmacy Network
  6. If You're Denied: Appeals Process
  7. Washington External Review Process
  8. Member Services & Support Contacts
  9. Cost Assistance Programs
  10. FAQ

Verify Your Blue Cross Plan

Washington has multiple Blue Cross Blue Shield carriers, each with slightly different processes:

  • Premera Blue Cross (most common in Western WA)
  • Regence BlueShield (Eastern WA and some Western WA areas)
  • Federal Employee Program (FEP) Blue Cross

Check your insurance card for the specific carrier name and member services number. This determines which forms, portals, and contacts you'll use.

Prior Authorization Forms & Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required for all Filspari prescriptions Plan-specific PA form via provider portal 7-14 business days
REMS Enrollment FDA safety program for prescriber and patient FDA REMS website Must complete before PA submission
Clinical Documentation IgAN diagnosis, prior treatments, lab values Medical records, specialist consultation Varies
Formulary Status Typically Tier 3 or non-formulary Plan formulary document Check annually

Step-by-Step: Fastest Path to Approval

  1. Confirm IgAN diagnosis (prescriber): Document primary IgA nephropathy with biopsy confirmation and risk factors for progression
  2. Enroll in REMS (prescriber and patient): Complete FDA-required safety program enrollment before prescribing
  3. Gather clinical evidence (prescriber): Collect UPCR/eGFR values, prior RAAS blocker trials, contraindications to alternatives
  4. Submit PA form (prescriber): Use plan-specific form via Availity (Premera) or plan portal with complete documentation
  5. Document pregnancy prevention (if applicable): Include negative pregnancy tests and contraception plans for females of childbearing potential
  6. Follow up in 7-14 days (patient/prescriber): Contact plan if no determination received
  7. If approved: Coordinate with in-network specialty pharmacy for dispensing

REMS Program Enrollment

The FDA requires both prescribers and patients to enroll in the Filspari REMS program due to hepatotoxicity and teratogenicity risks.

For Prescribers:

  • Complete REMS training modules
  • Agree to monitor liver function every 3 months (recently reduced from monthly)
  • Counsel patients on pregnancy risks and prevention

For Patients:

  • Understand hepatotoxicity risks and monitoring requirements
  • If female of childbearing potential: negative pregnancy test before starting, effective contraception throughout treatment
  • Regular follow-up for liver function monitoring
Note: REMS enrollment must be documented in your PA submission. Plans routinely deny requests lacking REMS compliance proof.

Submission Portals & Methods

Premera Blue Cross

  • Provider Portal: Availity Essentials
  • Support: 800-282-4548 for portal assistance
  • Fax: Check current provider directory (verify with source linked below)
  • Provider Services: 877-342-5258, option 1

Regence BlueShield

  • Provider Portal: Regence provider website login
  • Member Appeals Fax: 425-918-5592
  • Provider Services: 877-668-4651

Required Documentation for PA:

  • Completed plan-specific PA form
  • REMS enrollment confirmation
  • IgAN diagnosis with ICD-10 code
  • Prior treatment history and failures/intolerances
  • Current lab values (UPCR, eGFR, liver function)
  • Pregnancy prevention documentation (if applicable)

Specialty Pharmacy Network

Filspari must be obtained through in-network specialty pharmacies for coverage:

Premera Blue Cross Networks:

  • Accredo (Express Scripts specialty pharmacy)
  • AllianceRx Walgreens Prime (select plans)

Enrollment Process:

  1. Prescriber sends prescription to in-network specialty pharmacy
  2. Pharmacy contacts patient for enrollment and shipping arrangements
  3. Pharmacy may assist with PA process and appeals
  4. Home delivery typically available with 30- or 90-day supplies
Tip: Using out-of-network specialty pharmacies typically results in no coverage, leaving patients responsible for Filspari's ~$10,000 monthly cost.

If You're Denied: Appeals Process

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
Missing REMS enrollment Submit REMS confirmation Prescriber and patient enrollment proof
Insufficient clinical evidence Provide comprehensive medical records Biopsy results, specialist consultation, lab trends
Step therapy not met Document prior RAAS blocker failures Treatment history with dates, doses, outcomes
Non-formulary status Request formulary exception Medical necessity letter citing guidelines
Pregnancy risk concerns Address contraception plan Negative pregnancy tests, contraception documentation

Internal Appeals Timeline

  • File within: 180 days of denial notice
  • Standard review: Plan-specific timeline (typically 15-30 days)
  • Expedited review: 72 hours for urgent cases

Washington External Review Process

If your internal appeals are denied, Washington's Independent Review Organization (IRO) process provides an independent medical review.

Key Contacts:

External Review Process:

  1. Request within: 4 months of final internal denial
  2. IRO assignment: Plan assigns IRO via OIC system
  3. Timeline: Up to 20 days for fully-insured plans (72 hours for urgent)
  4. Decision: Binding on the insurance plan if overturned

Member Services & Support Contacts

Premera Blue Cross:

  • Member Services: 800-722-1471 (TTY: 711)
  • Pharmacy Services: 888-261-1756
  • Case Management: 844-996-0329

Regence BlueShield:

  • Member Services: 888-675-6570
  • 24/7 Pharmacy Support: 888-675-6570 (choose Pharmacy option)

Federal Employee Program:

  • Premera FEP: 800-562-1011
From our advocates: We've seen patients successfully overturn Filspari denials by working closely with their nephrologist to document clear IgAN progression risk factors and by ensuring REMS enrollment was completed before the PA submission. The key is thorough documentation that directly addresses the plan's medical necessity criteria.

Cost Assistance Programs

While pursuing coverage approval, explore these cost assistance options:

  • Travere Therapeutics Patient Support: Contact manufacturer for copay assistance and patient access programs
  • Foundation support: Organizations like the National Kidney Foundation may offer grant assistance
  • State programs: Washington Apple Health (Medicaid) expansion may provide alternative coverage

FAQ

How long does Blue Cross Blue Shield PA take in Washington? Standard prior authorizations typically take 7-14 business days. Expedited reviews for urgent cases must be completed within 72 hours per Washington regulations.

What if Filspari is non-formulary on my plan? You can request a formulary exception by submitting a medical necessity letter documenting why Filspari is medically necessary and why formulary alternatives are inappropriate.

Can I request an expedited appeal in Washington? Yes, if a delay would seriously jeopardize your health. Mark appeals as "urgent" and include supporting clinical documentation of the time-sensitive nature.

Does step therapy apply if I've tried medications outside Washington? Yes, document all prior treatments regardless of where they occurred. Include dates, doses, duration, and reasons for discontinuation or failure.

What happens if the IRO upholds the denial? The IRO decision is typically final, but you can contact the Washington OIC at 1-800-562-6900 for additional guidance or explore legal options.

How often should I check for updated forms and requirements? Review your plan's PA requirements annually during open enrollment and before each prescription refill, as policies can change.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and meeting procedural deadlines for coverage determinations and external reviews.

When navigating complex specialty drug approvals like Filspari, having the right documentation and following payer-specific workflows is crucial. Counterforce Health streamlines this process by identifying denial reasons and crafting appeals that address each plan's specific criteria and requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for the most current coverage requirements and procedures. Policies and contact information may change; verify all details with official sources before taking action.

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