By Counterforce Health Team in Filspari (sparsentan) —

How to Get Filspari (Sparsentan) Covered by Humana in North Carolina: Complete Guide with Forms, Appeals, and Cost-Saving Strategies

Answer Box: Fastest Path to Filspari Coverage

Filspari (sparsentan) is covered by Humana Medicare Advantage plans with prior authorization required. Your nephrologist submits a PA request with IgA nephropathy diagnosis, lab results (proteinuria/eGFR), and medical necessity letter via Humana's provider portal or fax (800-555-2546). Standard approval takes 30 days; expedited requests get 72-hour decisions for urgent cases. If denied, North Carolina residents can appeal internally (65 days) then request external review through Smart NC within 120 days. First step today: Have your doctor complete the Humana PA form with your biopsy-confirmed IgAN diagnosis and current kidney function tests.

Table of Contents

  1. What Drives Filspari Costs
  2. Investigating Your Humana Benefits
  3. Financial Assistance Options
  4. Prior Authorization Process
  5. Appeals Process in North Carolina
  6. Pharmacy Choice and Coordination
  7. Annual Renewal Planning
  8. Helpful Scripts and Templates
  9. FAQ

What Drives Filspari Costs

Filspari (sparsentan) is a first-in-class dual endothelin type-A/angiotensin II type-1 receptor antagonist 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, it typically lands on Tier 5 (specialty tier) of Medicare formularies, meaning higher cost-sharing.

Key cost factors include:

  • Formulary tier placement: Specialty drugs often require 33% coinsurance vs. fixed copays
  • Prior authorization requirements: Adds administrative steps but doesn't change coverage once approved
  • Specialty pharmacy mandates: May require mail-order through CenterWell Specialty Pharmacy
  • Quantity limits: Typically restricted to 30-day supplies for safety monitoring
Note: Humana's Medicare Advantage PA denial rate is approximately 3.5%—among the lowest of major insurers—but denials often stem from incomplete documentation rather than medical necessity.

Investigating Your Humana Benefits

Before starting the approval process, gather this essential information:

Coverage Details to Verify:

  1. Log into MyHumana or call Member Services (1-800-794-5907) to confirm:
    • Your plan's specific formulary tier for Filspari
    • Prior authorization requirements
    • Specialty pharmacy network restrictions
    • Your current deductible and out-of-pocket maximum
  2. Download your plan's Prescription Drug Guide from Humana's drug list portal
  3. Verify network pharmacies using the Pharmacy Directory or confirm CenterWell Specialty Pharmacy access

Financial Assistance Options

Manufacturer Support Programs

Travere TotalCare offers comprehensive support for commercially insured patients:

  • Copay Program: Reduces costs to as low as $0 per month (subject to annual maximum)
  • Patient Assistance Program: Free medication for up to 12 months for uninsured/underinsured patients
  • REMS Support: Free home lab testing for eligible patients

To apply: Call 1-833-FILSPARI (833-345-7727) or have your doctor submit the Patient Start Form from TravereTotalCare.com.

Important: Government-funded insurance patients (Medicare, Medicaid) are not eligible for manufacturer copay cards but may qualify for patient assistance programs.

Foundation Grants

IgA Nephropathy Foundation Patient Aid Fund

  • Covers copays, coinsurance, deductibles, and non-medical expenses
  • Eligibility: U.S. residents with physician-diagnosed IgAN via kidney biopsy
  • Application: Join as a free member at igan.org, then apply online with physician verification form and personal essay
  • Contact: (732) 770-7377

Additional National Programs:

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

1. Prescriber Preparation (1-2 days)

  • Gather IgAN diagnosis confirmation (kidney biopsy results)
  • Document current kidney function (proteinuria levels, eGFR)
  • Record prior treatment failures or contraindications
  • Complete REMS enrollment if not already done

2. Submit PA Request

  • Online: Humana provider portal (preferred method)
  • Phone: 800-555-2546 (Monday-Friday, 8am-6pm ET)
  • Fax: 866-856-8974 (Medicare plans)

3. Required Documentation:

  • Medical necessity letter addressing FDA-approved indication
  • Lab results showing proteinuria and kidney function decline
  • Prior therapy history (ACE inhibitors, ARBs, immunosuppressants)
  • ICD-10 diagnosis code N02.8 (IgA nephropathy)

4. Timeline Expectations:

  • Standard review: 30 days for Medicare Advantage
  • Expedited review: 72 hours for urgent medical situations
  • Part D appeals: 7 days standard timeline

Appeals Process in North Carolina

Internal Appeals with Humana

If your initial PA request is denied, you have 65 days from the denial notice to request a redetermination:

Submit appeals to:

  • Online: MyHumana member portal
  • Phone: Number on your denial letter
  • Mail: Address specified in denial notice

Required elements:

  • Copy of denial letter
  • Updated medical necessity letter addressing specific denial reasons
  • Additional clinical evidence (recent labs, imaging, consultant notes)

External Review Through Smart NC

North Carolina offers robust external review rights through Smart NC, part of the NC Department of Insurance.

Eligibility:

  • State-regulated health plan (most individual and group plans)
  • Exhausted internal appeals or qualify for expedited review
  • Denial based on medical necessity or experimental treatment determination

Process:

  1. Submit request within 120 days of final internal denial
  2. Forms available at NCDOI website or by calling Smart NC: 1-855-408-1212
  3. Standard review: Decision within 45 days
  4. Expedited review: Decision within 72 hours for urgent cases

Smart NC Advantages:

  • Free advocacy and guidance through the process
  • Help gathering medical records and clinical guidelines
  • IRO decision is binding on the insurer
  • Covers State Health Plan denials
From our advocates: "We've seen several IgAN patients successfully overturn Filspari denials through North Carolina's external review process. The key was submitting updated kidney function tests showing disease progression despite standard therapy, along with nephrologist letters citing the drug's FDA approval and clinical trial data. Smart NC's staff helped coordinate the medical records, making the process much smoother than expected."

Pharmacy Choice and Coordination

Specialty Pharmacy Requirements

Filspari typically requires dispensing through Humana's specialty pharmacy network:

CenterWell Specialty Pharmacy (Mail-Order)

  • 30-day supply limit
  • Lower copays compared to retail
  • Shipped to your home
  • Coordination with REMS monitoring

Network Retail Specialty Pharmacies

  • 30-day supply limit
  • Use for transitions or immediate needs
  • Verify network status through Pharmacy Directory

REMS Coordination

Filspari requires Risk Evaluation and Mitigation Strategy (REMS) enrollment due to hepatotoxicity risks:

  • Monitoring: ALT/AST every 3 months (recently reduced from monthly)
  • Pregnancy prevention: Required for women of childbearing potential
  • Pharmacy coordination: REMS-certified pharmacies only

Annual Renewal Planning

What Can Change:

  • Formulary tier placement (reviewed annually)
  • Prior authorization requirements
  • Network pharmacy changes
  • Cost-sharing amounts

Renewal Checklist:

  • Review Annual Notice of Change (ANOC) in September
  • Confirm Filspari remains covered for next plan year
  • Update financial assistance program enrollment
  • Schedule annual nephrologist visit before plan changes

Budget Planning:

  • Medicare out-of-pocket maximum: $2,100 for 2026
  • Specialty tier typically 33% coinsurance
  • Factor in REMS monitoring lab costs

Helpful Scripts and Templates

Patient Script for Humana Member Services

"Hi, I'm calling about prior authorization for Filspari, generic name sparsentan, for IgA nephropathy. My member ID is [number]. Can you tell me the current PA requirements, formulary tier, and whether it requires specialty pharmacy? I also need to know the appeal process if it's initially denied."

Clinician Medical Necessity Letter Template

Key elements to address:

  • Confirmed IgA nephropathy diagnosis via kidney biopsy
  • Current proteinuria levels and eGFR decline
  • Prior therapy failures (ACE/ARB, immunosuppressants)
  • Contraindications to alternative therapies
  • Filspari's FDA approval for this specific indication
  • Expected clinical benefits and monitoring plan

Pharmacy Coordination Script

"I need to fill Filspari (sparsentan) and understand it requires REMS enrollment and specialty pharmacy dispensing. Can you confirm you're REMS-certified and in my Humana network? What's the typical timeline for first fill after PA approval?"

FAQ

How long does Humana PA take for Filspari in North Carolina? Standard PA decisions take 30 days for Medicare Advantage plans. Expedited reviews (for urgent medical situations) are completed within 72 hours.

What if Filspari is non-formulary on my Humana plan? You can request a formulary exception by demonstrating medical necessity. Your prescriber must show that formulary alternatives would be less effective or cause adverse effects for your condition.

Can I request an expedited appeal in North Carolina? Yes, both Humana internal appeals and North Carolina external reviews offer expedited processes for urgent medical situations where delays could seriously jeopardize your health.

Does step therapy apply if I've tried therapies outside North Carolina? Yes, documented prior therapy failures from any location count toward step therapy requirements. Ensure your new North Carolina nephrologist has complete records from previous providers.

What happens if Smart NC overturns my denial? The external review decision is binding. If Smart NC determines Filspari should be covered, Humana must provide coverage within 3 business days of the decision.

Are there income limits for manufacturer assistance programs? Travere TotalCare's copay program doesn't publish specific income limits, but eligibility is determined during enrollment. The Patient Assistance Program is designed for uninsured/underinsured patients and does consider financial need.

Sources & Further Reading

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and payer policies to draft point-by-point rebuttals aligned with each plan's specific requirements, incorporating the right clinical evidence and procedural details that payers expect. For complex cases like Filspari coverage, Counterforce Health streamlines the appeals process by identifying denial patterns and crafting compelling medical necessity arguments that address payer-specific workflows and documentation requirements.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual circumstances and plan details. Always consult with your healthcare provider and insurance plan for personalized guidance. For official North Carolina insurance assistance, contact Smart NC at 1-855-408-1212.

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