By Counterforce Health Team in Filspari (sparsentan) —

How to Get Filspari (sparsentan) Covered by Humana in Michigan: Complete PA Guide and Appeal Process

Answer Box: Your Path to Filspari Coverage

To get Filspari (sparsentan) covered by Humana in Michigan: You need biopsy-proven IgA nephropathy with persistent proteinuria ≥1g/day despite ACE inhibitor/ARB therapy, plus enrollment in the FDA REMS program with quarterly liver function tests. Submit prior authorization through your nephrologist using Humana's provider portal with complete documentation. If denied, you have 65 days to appeal internally, then 127 days to file for Michigan DIFS external review. Start today: Confirm your diagnosis meets criteria and gather your biopsy report, recent labs (eGFR, urine protein), and prior therapy records.

Table of Contents

  1. Do You Qualify? Quick Eligibility Check
  2. Coverage Requirements at a Glance
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Playbook for Michigan
  6. Clinician Corner: Medical Necessity Documentation
  7. Costs and Patient Support Programs
  8. When to Escalate to State Regulators
  9. Frequently Asked Questions

Do You Qualify? Quick Eligibility Check

Likely Eligible ✅

  • Confirmed IgA nephropathy with kidney biopsy showing IgA-dominant deposits
  • Persistent proteinuria ≥1.0 g/day (or uPCR ≥1000 mg/g) despite optimized supportive care
  • Trial of ACE inhibitor or ARB for ≥3 months at maximum tolerated dose (or documented intolerance)
  • eGFR ≥20 mL/min/1.73m² (not on dialysis)
  • Age 18 or older
  • No pregnancy or severe liver impairment

Possibly Eligible ⚠️

  • Proteinuria 0.5-1.0 g/day with high-risk features (declining eGFR, young age, Oxford MEST-C score E1 or higher)
  • Recent IgAN diagnosis with suboptimal ACE inhibitor/ARB trial duration
  • Borderline eGFR (20-25 mL/min/1.73m²) requiring nephrologist assessment

Not Yet Eligible ❌

  • No kidney biopsy or unclear IgAN diagnosis
  • Proteinuria <0.5 g/day without high-risk features
  • Pregnancy or planning pregnancy
  • Severe liver disease or ALT/AST >3x upper limit normal
  • eGFR <20 mL/min/1.73m² or on dialysis

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Humana plans Humana PA Search Tool Humana Provider Portal
REMS Enrollment FDA-mandated safety program FILSPARIREMS.com FDA REMS
Quarterly LFTs Liver function tests every 3 months Your nephrologist's office FDA Prescribing Information
Specialist Requirement Nephrologist must prescribe Provider directory Humana Coverage Policy
Formulary Status Tier 5/6 specialty drug Humana Drug List 2026 Formulary

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis (Patient + Nephrologist)

What you need: Kidney biopsy report showing IgA nephropathy, recent urine protein/creatinine ratio, eGFR results Timeline: Can be done immediately if records exist Where to submit: Gather for PA submission

2. Document Prior Therapy Failures (Nephrologist)

What you need: Records showing ≥3 months of ACE inhibitor or ARB at maximum tolerated dose, with persistent proteinuria Timeline: Historical records or 3+ month trial if not yet attempted Submit via: Include in PA documentation

3. Enroll in REMS Program (Nephrologist + Patient)

What you need: Complete prescriber and patient enrollment forms, baseline liver function tests Timeline: Must be completed before first prescription Submit via: FILSPARIREMS.com or fax 1-833-483-4736

4. Submit Prior Authorization (Nephrologist)

What you need: Complete PA form with all supporting documentation Timeline: Humana responds within 7 days (72 hours if expedited) Submit via: Humana Provider Portal (preferred) or fax

5. Track Your Request (Patient + Nephrologist)

What you need: PA confirmation number Timeline: Check status after 3-5 business days Submit via: Provider portal or call Humana member services

Tip: Humana processes 95% of electronic PA requests within 1 business day when submitted through their provider portal with complete documentation.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"REMS enrollment incomplete" Submit proof of enrollment REMS confirmation, recent LFTs
"Insufficient prior therapy" Document ACE/ARB trial details Prescription records, pharmacy fills, side effect notes
"Diagnosis not confirmed" Provide biopsy results Pathology report with IgA deposits, Oxford MEST-C scoring
"Proteinuria not severe enough" Submit recent labs Multiple uPCR results showing ≥1g/day
"Non-formulary drug" Request formulary exception Medical necessity letter comparing to alternatives

Appeals Playbook for Michigan

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • Timeline: Humana responds within 7 days (72 hours expedited)
  • How to file: Humana Provider Portal or member services
  • Required: Denial letter, medical records, prescriber letter

Michigan DIFS External Review

Note: Michigan gives you 127 days to file for external review—longer than the federal 120-day requirement, giving patients extra time to gather documentation.

Expedited Appeals for Urgent Cases

If waiting for Filspari approval would jeopardize your health, request expedited review:

  • Required: Physician letter stating delay would harm patient
  • Timeline: 72 hours for decision
  • Eligibility: Pre-service denials only (not post-service claims)

Clinician Corner: Medical Necessity Documentation

Medical Necessity Letter Checklist

Essential elements for Humana approval:

  1. Patient identification: Full name, DOB, Humana ID, diagnosis with ICD-10 code (N02.8 - IgA nephropathy)
  2. Clinical history: Biopsy date and findings, Oxford MEST-C score if available, current eGFR and proteinuria levels
  3. Prior therapy documentation: Specific ACE inhibitor/ARB used, doses, duration, outcomes, reasons for inadequate response
  4. Treatment rationale: Why Filspari is medically necessary, expected outcomes, monitoring plan
  5. Supporting evidence: Reference FDA approval, clinical trial data (PROTECT study), nephrology guidelines

Key Clinical Criteria to Address

  • Primary IgA nephropathy (exclude secondary causes)
  • Proteinuria ≥1.0 g/day despite optimal supportive care
  • eGFR 25-75 mL/min/1.73m² at treatment initiation (FDA label range)
  • REMS compliance plan with quarterly liver monitoring
  • Contraindication assessment (pregnancy, liver disease, drug interactions)

Counterforce Health helps clinicians streamline this documentation process by automatically generating evidence-backed appeal letters that align with payer-specific requirements and FDA labeling.

Costs and Patient Support Programs

Filspari Pricing and Coverage

  • List price: Approximately $9,900-$10,038 per 30-day supply
  • Humana coverage: Typically Tier 5/6 specialty with prior authorization
  • 2026 changes: Medicare Part D out-of-pocket cap of $2,100 (includes all copays and coinsurance)

Patient Assistance Options

  • Travere TotalCare: Manufacturer support program at traveretotalcare.com
  • Medicare Extra Help: Low-income subsidy program reducing copays
  • State pharmaceutical assistance: Check Michigan-specific programs through DIFS

When to Escalate to State Regulators

Contact Michigan DIFS if you experience:

  • Repeated inappropriate denials despite meeting coverage criteria
  • Delayed responses beyond Humana's required timelines
  • Procedural violations in the appeals process

Michigan DIFS Contact:

  • Phone: 877-999-6442 (toll-free)
  • Website: michigan.gov/difs
  • Email: Available through online complaint form

Frequently Asked Questions

Q: How long does Humana prior authorization take for Filspari in Michigan? A: Standard PA decisions within 7 days; expedited within 72 hours. Electronic submissions through the provider portal are often decided within 1 business day.

Q: What if Filspari is not on Humana's formulary? A: Request a formulary exception with medical necessity documentation. Humana must provide transition coverage for the first 31 days while processing your request.

Q: Can I request an expedited appeal if my kidney function is declining? A: Yes, if your nephrologist provides written documentation that delay would jeopardize your health. Michigan DIFS decides expedited external appeals within 72 hours.

Q: Do I need to try other IgA nephropathy treatments first? A: Yes, you must have tried and failed (or been intolerant to) ACE inhibitor or ARB therapy for at least 3 months at maximum tolerated dose.

Q: What happens if I miss the REMS liver function tests? A: Your pharmacy cannot dispense Filspari without current LFTs. Schedule tests every 3 months and ensure results are sent to your prescriber and the REMS program.

Q: How do I track my appeal status? A: Use Humana's member portal online or call member services. For Michigan DIFS external reviews, call 877-999-6442 with your case number.

From Our Advocates

"We've seen patients successfully overturn Filspari denials by ensuring their nephrologist clearly documents the progression risk factors—like persistent proteinuria above 1g/day despite optimal ACE inhibitor therapy, or concerning biopsy findings with Oxford scoring. The key is connecting clinical data to FDA-approved indications in language that utilization management teams understand. Most approvals come through on the first internal appeal when documentation is complete."

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Filspari. Our platform analyzes denial letters, identifies the specific coverage gaps, and generates point-by-point rebuttals using FDA labeling, clinical guidelines, and payer-specific criteria to help patients and providers navigate the prior authorization and appeals process more effectively.

Sources & Further Reading

Medical Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your nephrologist to determine if Filspari is appropriate for your specific condition. Coverage policies may vary by plan and change over time—verify current requirements with Humana and your healthcare team.

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