By Counterforce Health Team in Filspari (sparsentan) —

How to Get Filspari (sparsentan) Covered by Humana in New Jersey: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Filspari Covered by Humana in New Jersey

Filspari (sparsentan) requires prior authorization from Humana and is dispensed only through specialty pharmacies. To get coverage in New Jersey: 1) Complete REMS enrollment for both patient and prescriber, 2) Submit PA with biopsy-proven IgA nephropathy diagnosis, UPCR ≥0.8 g/g, and ACE inhibitor failure documentation, 3) If denied, file internal appeal within 65 days, then external review through New Jersey's IHCAP within 4 months. Start today by verifying REMS enrollment and gathering required lab results.

Table of Contents

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Humana plans Humana Provider Portal
Formulary Tier Specialty tier (highest cost-sharing) Humana Drug Lists
Dispensing Specialty pharmacy only, mail order Confirmed during PA approval
REMS Program Both prescriber and patient enrollment required FDA REMS Information
Diagnosis Code N02.8 or N05.8 (IgA nephropathy) Medical records/billing
Appeals Deadline 65 days (internal), 4 months (external) NJ IHCAP

Step-by-Step: Fastest Path to Approval

1. Verify REMS Enrollment (Patient + Prescriber)

Who: Prescriber's office
Document: REMS enrollment confirmation
Timeline: 1-2 business days
Submit: Complete before PA submission

2. Gather Required Documentation

Who: Patient and nephrologist
Documents needed:

  • Kidney biopsy report confirming IgA nephropathy
  • Recent UPCR ≥0.8 g/g or 24-hour urine ≥1 g/day
  • Current eGFR ≥30 mL/min/1.73m²
  • Baseline and recent liver function tests
  • Documentation of ACE inhibitor or ARB failure (minimum 12 weeks)

3. Submit Prior Authorization

Who: Prescriber
How: Humana Provider Portal or fax to 877-486-2621
Timeline: 7-14 days for standard review
Phone support: 1-866-488-5995

4. Track PA Status

Who: Patient or clinic staff
How: Provider portal or member services
Timeline: Check after 5-7 business days

5. If Approved: Coordinate Specialty Pharmacy

Who: Humana assigns specialty pharmacy
Timeline: 3-5 days for first shipment
Note: Retail pharmacies cannot dispense Filspari

6. If Denied: File Internal Appeal

Who: Patient or prescriber
Timeline: Within 65 days of denial notice
How: Written appeal with additional evidence

7. External Review (If Needed)

Who: Patient
Timeline: Within 4 months of final denial
Process: New Jersey IHCAP external review

Medical Necessity Requirements

Core Documentation for Humana PA

Diagnosis Requirements:

  • Biopsy-proven primary IgA nephropathy (pathology report required)
  • ICD-10 codes: N02.8 (recurrent and persistent hematuria with other morphologic changes) or N05.8 (unspecified nephritic syndrome with other morphologic changes)

Laboratory Evidence:

  • Proteinuria: UPCR ≥0.8 g/g or 24-hour urine protein ≥1 g/day
  • Kidney function: Current eGFR documenting kidney function (typically ≥30 mL/min/1.73m²)
  • Liver monitoring: Baseline ALT/AST within 3 months

Treatment History:

  • Documented trial and failure/intolerance of optimized ACE inhibitor or ARB therapy
  • Minimum 12-week trial with specific medications, doses, and failure reasons
  • Blood pressure and proteinuria response data preferred
Clinician Corner: Your medical necessity letter should address each denial criterion point-by-point. Include specific lab values with dates, prior medication trials with exact dosages and durations, and cite the FDA prescribing information for approved indications. Reference kidney disease progression risk factors and treatment goals.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing REMS enrollment Submit proof of completed prescriber and patient REMS registration
Insufficient proteinuria documentation Provide recent UPCR ≥0.8 g/g or 24-hour urine ≥1 g/day with lab report
No prior ACE inhibitor/ARB trial Document specific medications tried, doses, duration (≥12 weeks), and failure reasons
Incomplete diagnosis documentation Submit kidney biopsy pathology report confirming primary IgA nephropathy
Missing liver function tests Provide baseline ALT/AST results within past 3 months
Non-specialist prescriber Transfer prescription to nephrologist or provide nephrology consultation note

Appeals Process for New Jersey

Internal Appeals with Humana

Timeline: 65 days from denial notice
How to file:

  • Online: Humana member portal
  • Mail: Address provided in denial letter
  • Phone: Member services number on insurance card

Required documents:

  • Copy of denial letter
  • Additional medical records supporting medical necessity
  • Prescriber letter addressing specific denial reasons
  • Updated lab results if available

External Review through NJ IHCAP

New Jersey's Independent Health Care Appeals Program (IHCAP) provides an independent review when Humana's internal appeals are exhausted.

Eligibility: Must complete Humana's internal appeal process first
Timeline: Within 4 months (120 days) of final denial
Process: Managed by Maximus Federal Services

Standard Review: Decision within 45 calendar days
Expedited Review: Decision within 48 hours for urgent cases

Required Documentation:

  • IHCAP external appeal form
  • General release for medical records
  • Copies of all denial letters
  • Supporting medical evidence
  • Physician letters explaining medical necessity
Note: The IHCAP review is binding on Humana. If approved, Humana must authorize coverage within 10 business days.

Cost and Assistance Options

Manufacturer Support Programs

Travere TotalCare® Copay Program:

  • Eligibility: Commercial insurance only (Medicare patients excluded)
  • Benefit: As low as $0 per month
  • Contact: 1-833-345-7727 or TravereTotalCare.com

Patient Assistance Program:

  • Free medication for up to 12 months for uninsured/underinsured patients
  • Bridge Program for coverage gaps or delays

Medicare Patients

Medicare patients cannot use manufacturer copay assistance but may qualify for:

  • Extra Help/Low-Income Subsidy (LIS): Reduces Part D costs
  • State Pharmaceutical Assistance Programs: Check New Jersey eligibility
  • Patient advocacy foundations: Disease-specific grant programs

Specialty Pharmacy Coordination

Filspari must be dispensed through Humana's contracted specialty pharmacy network. The specialty pharmacy will:

  • Coordinate with your prescriber for refills
  • Manage REMS monitoring requirements
  • Provide medication counseling and support
  • Handle insurance coordination and copay assistance enrollment

Scripts for Key Conversations

Calling Humana Member Services

"Hi, I'm calling about a prior authorization request for Filspari, generic name sparsentan, for my IgA nephropathy. My member ID is [number]. Can you tell me the status of my PA request submitted on [date]? If it was denied, I'd like to understand the specific reasons and request the written denial notice be sent to me."

Requesting Peer-to-Peer Review

"I'm calling to request a peer-to-peer review for my patient's Filspari prior authorization that was denied. The patient has biopsy-proven IgA nephropathy with significant proteinuria and has failed ACE inhibitor therapy. I'd like to discuss the medical necessity with the reviewing physician. When can we schedule this call?"

Pharmacy Coordination

"I have a patient with an approved Filspari prior authorization through Humana. Can you confirm which specialty pharmacy they've assigned for dispensing? I need to send the prescription and ensure the REMS requirements are coordinated."

Frequently Asked Questions

How long does Humana's prior authorization take for Filspari?
Standard PA decisions are typically made within 7-14 business days. You can request expedited review (72 hours) if there's urgent medical need.

What if Filspari isn't on my Humana formulary?
Filspari is typically on the specialty tier of most Humana formularies. If it's non-formulary, you can request a formulary exception with medical necessity documentation.

Can I get Filspari from my regular pharmacy?
No. Filspari must be dispensed through Humana's specialty pharmacy network due to REMS requirements and specialty drug designation.

What happens if my appeal is denied?
After exhausting Humana's internal appeals, you can file an external review through New Jersey's IHCAP program within 4 months of the final denial.

Does step therapy apply to Filspari?
Yes, most plans require documentation of ACE inhibitor or ARB failure before approving Filspari for IgA nephropathy.

How much will Filspari cost with Humana?
As a specialty tier medication, costs depend on your specific plan's benefit design. With Medicare Part D, you'll pay $0 after reaching the $2,100 out-of-pocket threshold in 2025.

Can my family doctor prescribe Filspari?
While any licensed physician can prescribe Filspari, Humana typically prefers or requires a nephrologist for specialty drug prior authorizations.

When to Escalate

Contact New Jersey Insurance Regulators

If you believe Humana is inappropriately denying coverage or not following proper procedures:

New Jersey Department of Banking and Insurance
Consumer Hotline: 1-800-446-7467
IHCAP-specific: 1-888-393-1062
Website: nj.gov/dobi

Federal Medicare Appeals (Medicare Advantage)

For Humana Medicare Advantage plans, federal appeal rights apply:

  • Level 1: Plan reconsideration (60 days)
  • Level 2: Independent Review Entity
  • Level 3: Administrative Law Judge hearing
  • Level 4: Medicare Appeals Council
  • Level 5: Federal District Court

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed, targeted rebuttals. Our platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point appeals aligned to each payer's requirements, pulling the right medical evidence and meeting procedural deadlines.

From our advocates: We've seen many Filspari appeals succeed when prescribers include specific proteinuria progression data and clearly document why ACE inhibitors failed or caused intolerable side effects. The key is addressing each denial criterion with concrete clinical evidence rather than general statements about medical necessity.

Disclaimer: This guide is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For personalized assistance with appeals, consider consulting with Counterforce Health or qualified patient advocates.

Sources & Further Reading

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