By Counterforce Health Team in Filspari (sparsentan) —

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

Quick Answer: Getting Filspari Covered by Humana in Ohio

Filspari (sparsentan) requires prior authorization from Humana with mandatory REMS enrollment and IgA nephropathy documentation. Submit PA through Humana's provider portal with kidney biopsy, UPCR ≥0.5-0.8 g/g, ACE/ARB failure records, and baseline liver tests. If denied, appeal within 65 days, then request Ohio external review within 180 days through the Ohio Department of Insurance. First step today: Call Humana at 1-866-488-5995 to verify your plan's specific Filspari requirements and get the PA form.

Table of Contents

  1. Coverage Requirements Overview
  2. Prior Authorization Process
  3. REMS Enrollment Requirements
  4. Cost-Saving Strategies
  5. Appeals Process for Ohio
  6. Specialty Pharmacy Requirements
  7. Common Scripts and Templates
  8. Frequently Asked Questions

Coverage Requirements Overview

Filspari (sparsentan) is a first-in-class dual endothelin/angiotensin receptor antagonist approved for adults with primary IgA nephropathy at risk for disease progression. Humana covers Filspari as a specialty drug requiring prior authorization across all lines of business.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization PA required before coverage Humana pharmacy PA portal Humana Provider
REMS Enrollment Prescriber and patient must enroll FILSPARI REMS website FDA/Manufacturer
Specialty Pharmacy Must use designated network CenterWell Specialty Humana Pharmacy
IgA Nephropathy Diagnosis Biopsy-confirmed primary IgAN Medical records Clinical Documentation
UPCR Threshold ≥0.5-0.8 g/g proteinuria Recent lab results Humana PA criteria

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic)
    • Call Humana at 1-866-488-5995 with member ID
    • Confirm Filspari is on formulary and PA requirements
    • Timeline: Same day
  2. Complete REMS Enrollment (Prescriber/Patient)
    • Prescriber enrolls at FILSPARI REMS website
    • Patient completes enrollment forms
    • Timeline: 1-2 business days
  3. Gather Clinical Documentation (Clinic)
    • Kidney biopsy report confirming IgA nephropathy
    • Recent UPCR and eGFR labs
    • ACE inhibitor/ARB trial history
    • Timeline: 2-3 days
  4. Submit Baseline Labs (Patient/Clinic)
    • ALT, AST, and bilirubin within 3 months
    • Required for REMS compliance
    • Timeline: Same day if recent
  5. Complete PA Form (Prescriber)
  6. Submit Complete Package (Clinic)
    • PA form + all documentation
    • REMS confirmation numbers
    • Timeline: Same day
  7. Follow Up (Patient/Clinic)
    • Standard decision: 7-14 days
    • Expedited: 72 hours if urgent
    • Timeline: As specified

Medical Necessity Criteria

Based on Humana's pharmacy coverage policy, approval requires:

Diagnosis Requirements:

  • Primary IgA nephropathy confirmed by kidney biopsy
  • Proteinuria (UPCR ≥0.8 g/g or 24-hour urine protein ≥1 g/day)
  • eGFR ≥30 mL/min/1.73 m²

Treatment History:

  • Documented trial of ACE inhibitor or ARB for ≥12 weeks
  • Maximum tolerated dose achieved
  • Inadequate response, intolerance, or contraindication documented

Safety Requirements:

  • Baseline liver function tests within normal limits
  • REMS enrollment completed
  • Prescriber specialty (nephrology preferred)
Clinician Corner: Medical Necessity Letter Checklist

Your letter should address:Specific IgA nephropathy diagnosis with biopsy dateCurrent proteinuria levels and trend over timePrior RAAS blockade trials: drug names, doses, duration, and outcomesRisk factors for progression (age, proteinuria level, eGFR decline)Treatment goals and monitoring planFDA label indications and guideline support

REMS Enrollment Requirements

The FILSPARI REMS program requires enrollment before prescribing due to hepatotoxicity risks.

Prescriber Requirements

  • Complete REMS certification training
  • Enroll in FILSPARI REMS portal
  • Counsel patients on liver monitoring
  • Order baseline and quarterly liver function tests

Patient Requirements

  • Complete REMS enrollment and acknowledgment forms
  • Understand hepatotoxicity risks and monitoring plan
  • Commit to quarterly liver function testing
  • Provide pregnancy status if applicable (contraindicated in pregnancy)

Documentation for PA

Include REMS confirmation numbers or screenshots showing:

  • Prescriber REMS certification completion
  • Patient REMS enrollment confirmation
  • Baseline ALT, AST, and bilirubin results

Cost-Saving Strategies

Understanding Your Costs

Filspari's list price is approximately $9,900-$10,038 per 30-day supply. Your out-of-pocket costs depend on:

  • Formulary tier placement (typically specialty tier)
  • Coverage phase (deductible, initial coverage, coverage gap, catastrophic)
  • Plan type (Medicare Advantage vs. Part D standalone)

Financial Assistance Options

For Commercial Insurance:

For Medicare/All Patients:

  • Travere Patient Assistance Program: Income-based free drug program
  • Bridge Program: Temporary free drug during coverage delays
  • Medicare Extra Help: Reduces deductibles and copays for qualifying incomes
  • PAN Foundation: Grants for kidney disease patients

2025 Medicare Part D Changes

The Medicare Part D redesign caps annual out-of-pocket costs at $2,000 starting in 2025, providing significant savings for Filspari patients.

From Our Advocates

We've seen patients successfully reduce their Filspari costs from $3,000+ monthly to under $50 by combining manufacturer assistance with Medicare Extra Help eligibility. The key is applying for all available programs simultaneously rather than trying one at a time, as approval timelines can overlap favorably.

Appeals Process for Ohio

Humana Internal Appeals

If your PA is denied, you have 65 days to file an internal appeal:

  1. Level 1 Appeal
    • Submit within 65 days of denial notice
    • Include additional medical records and physician letter
    • Standard timeline: 30 days for Medicare Advantage, 7 days for Part D
    • Expedited: 72 hours if delay could jeopardize health
  2. Level 2 Appeal (if Level 1 denied)
    • Automatic for Medicare; must request for commercial plans
    • Independent review by different Humana team
    • Same timelines as Level 1

Ohio External Review

After exhausting Humana's internal appeals, Ohio residents can request external review through the Ohio Department of Insurance.

Eligibility:

  • Denial based on medical necessity or experimental/investigational status
  • Internal appeals completed
  • Not purely contractual exclusions

Process:

  • Submit written request to Humana within 180 days of final denial
  • Ohio DOI assigns Independent Review Organization (IRO)
  • Standard review: 30 business days
  • Expedited review: 72 hours for urgent cases
  • IRO decision is binding on Humana

Contact Information:

When to Escalate

Contact Ohio DOI if:

  • Humana doesn't respond within required timeframes
  • You're told external review isn't available (ODI can override)
  • Procedural violations occur during appeals

Specialty Pharmacy Requirements

Filspari must be dispensed through Humana's specialty pharmacy network, typically CenterWell Specialty Pharmacy.

Why Specialty Pharmacy?

  • Clinical support: Pharmacists trained in IgA nephropathy management
  • REMS coordination: Handles liver monitoring requirements
  • Insurance navigation: Processes PAs and appeals
  • Home delivery: Up to 90-day supplies shipped directly

Transition Policy

For new members or non-formulary situations, Humana provides one-time 30-day supply at retail pharmacies during first 90 days while PA is processed.

Counterforce Health helps patients navigate complex insurance requirements like Filspari's PA and REMS enrollment by turning denial letters into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific policies.

Common Scripts and Templates

Patient Script for Calling Humana

"Hi, I'm calling about prior authorization for Filspari, generic name sparsentan, for my IgA nephropathy. My member ID is [ID number]. Can you tell me:

  • Is Filspari on my plan's formulary?
  • What tier is it on and what's my copay?
  • What documentation is needed for PA approval?
  • Can you email me the PA form?
  • What's the fax number for submissions?"

Clinic Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for [patient name] regarding Filspari for IgA nephropathy. The patient has biopsy-confirmed disease with UPCR of [value], has failed ACE inhibitor therapy due to [reason], and meets all REMS requirements. When can we schedule the clinical review with your medical director?"

Email Template for Medical Records

Subject: Urgent - Medical Records Needed for Filspari PA

"Dear [Provider],

We need the following records for [patient name]'s Filspari prior authorization by [deadline]:

  • Kidney biopsy report from [date]
  • Recent UPCR and eGFR results
  • Documentation of ACE inhibitor trial and outcome
  • Current nephrology consultation notes

Please fax to [number] or secure email to [address]. Thank you for your prompt attention."

Frequently Asked Questions

How long does Humana PA take for Filspari in Ohio? Standard PA decisions take 7-14 days. Expedited reviews are completed within 72 hours if delay could jeopardize health. Source: Humana PA timelines

What if Filspari is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Humana must respond within the same timeframes as standard PA requests.

Can I request an expedited appeal in Ohio? Yes, if delay could seriously jeopardize your health. Submit oral/electronic request to Humana, then provide written confirmation within 5 days.

Does step therapy apply if I've failed ACE inhibitors outside Ohio? Documentation of prior therapy trials from any location counts toward step therapy requirements, provided medical records are available.

What counts as medical necessity for Filspari? Humana's criteria require biopsy-confirmed IgA nephropathy with proteinuria ≥0.8 g/g and inadequate response to optimized RAAS blockade.

How do I find Ohio-specific appeal forms? The Ohio Department of Insurance provides external review forms and instructions specific to Ohio residents.

What if my employer plan is self-funded? Self-funded ERISA plans may not be subject to Ohio external review, but many voluntarily provide similar processes. Check your plan documents or contact HR.

Can Counterforce Health help with my Filspari appeal? Yes, Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing denial letters and plan policies to create evidence-backed rebuttals that address each payer's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions vary by plan and individual circumstances. Always consult with your healthcare provider about treatment options and contact your insurance company or the Ohio Department of Insurance for plan-specific guidance. For assistance with complex coverage issues, consider consulting with organizations like Counterforce Health that specialize in insurance appeals and prior authorization support.

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