By Counterforce Health Team in Filspari (sparsentan) —

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

Quick Answer: Getting Filspari (sparsentan) Covered by Humana in Pennsylvania

Filspari (sparsentan) requires prior authorization from Humana in Pennsylvania. First step: Complete REMS enrollment for both prescriber and patient at filsparirems.com. Then submit Humana's PA request with IgA nephropathy biopsy confirmation, UPCR ≥0.5 g/g, and eGFR documentation. If denied, you have 65 days to appeal internally, followed by Pennsylvania's independent external review (50% overturn rate). For urgent cases, request expedited review within 72 hours.

Start today: Verify your Humana plan covers specialty drugs and contact your nephrologist to begin REMS enrollment.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines
  7. If You're Asked for More Information
  8. If Your Request is Denied
  9. Renewal and Re-authorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps Pennsylvania residents with Humana Medicare Advantage or Part D plans navigate the prior authorization process for Filspari (sparsentan), a specialty medication for IgA nephropathy. We'll walk through each step, from REMS enrollment to appeals, with specific forms, phone numbers, and timelines for Pennsylvania.

Filspari costs approximately $10,000 per month, making prior authorization essential for coverage. With proper documentation and persistence, most medically appropriate requests are approved.

Before You Start: Plan Verification

Confirm Your Coverage Type

First, verify you have a Humana plan regulated by Pennsylvania (not a self-funded employer plan). Check your insurance card or call Humana customer service at the number on your card.

Check Formulary Status

Use Humana's drug list search to confirm Filspari is covered under your specific plan. Filspari is typically placed on the specialty tier with the highest cost-sharing, but coverage varies by plan.

Verify Network Status

Ensure your prescribing nephrologist is in-network with your Humana plan. Out-of-network prescriptions face additional hurdles and higher costs.

Gather Required Documentation

REMS Program Requirements

Before any coverage consideration, both prescriber and patient must enroll in the Filspari REMS program:

  • Prescriber: Complete REMS certification and enrollment form
  • Patient: Submit patient enrollment form
  • Monitoring: Quarterly liver function tests (ALT/AST) are required

Contact the REMS program at 1-833-513-1325 for forms and guidance.

Medical Documentation Checklist

✓ IgA Nephropathy Diagnosis

  • Kidney biopsy report confirming IgA immune complex deposits
  • ICD-10 diagnosis code (typically N02.8 or N05.8)

✓ Laboratory Values

  • Recent UPCR (urine protein-to-creatinine ratio) ≥0.5 g/g
  • Current eGFR (estimated glomerular filtration rate) ≥30 mL/min/1.73m²
  • Baseline liver function tests

✓ Prior Therapy Documentation

  • Records of ACE inhibitors or ARBs tried
  • Response to previous treatments
  • Contraindications or intolerances

✓ Clinical Notes

  • Specialist consultation notes
  • Treatment goals and prognosis
  • Risk of disease progression

Submit Your Prior Authorization Request

Online Submission

  1. Log into the Humana provider portal (for prescribers)
  2. Navigate to prior authorization requests
  3. Complete the "Request for Medicare Prescription Drug Coverage Determination" form
  4. Upload supporting documentation

Fax Submission

Submit completed forms to 877-486-2621 with all supporting documentation attached.

Phone Support

For questions during submission, call Humana's Medicare pharmacy prior authorization line at 1-866-488-5995.

Tip: Submit requests early in the week to avoid weekend processing delays.

Coverage Requirements at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all Humana plans Humana PA Search Tool Humana Policy
REMS Enrollment Prescriber and patient must enroll filsparirems.com FDA REMS
Specialty Pharmacy May be required Humana will specify during PA Plan Documents
Quarterly Monitoring Liver function tests every 3 months Prescriber responsibility FDA Label
Diagnosis Confirmation IgA nephropathy by biopsy Medical records KDIGO Guidelines

Follow-Up and Tracking

Standard Timeline

Humana has 7 days for standard Part D prior authorization decisions and 72 hours for expedited requests.

Tracking Your Request

  • Reference number provided at submission
  • Check status via provider portal or customer service
  • Document all phone calls with date, time, and representative name

Sample Follow-Up Script

"I'm calling to check the status of prior authorization request #[NUMBER] for Filspari submitted on [DATE]. Can you provide an update and expected decision date?"

Typical Timelines

Standard Prior Authorization: 7 days maximum Expedited Review: 72 hours (for urgent medical situations) Internal Appeal: 7 days for standard, 72 hours for expedited External Review: 45 days standard, 72 hours expedited

Pennsylvania law requires these timelines be met, with penalties for delays.

If You're Asked for More Information

Humana may request additional clinical information. Common requests include:

  • More detailed treatment history
  • Specialist consultation notes
  • Literature supporting off-label use
  • Peer-to-peer review with medical director

Respond promptly with requested documentation to avoid delays.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason Solution
REMS enrollment incomplete Complete enrollment at filsparirems.com
Insufficient diagnosis documentation Provide kidney biopsy report
Missing lab values Submit recent UPCR and eGFR results
Step therapy not met Document ACE/ARB trials and outcomes
Quantity limits exceeded Justify dosing with clinical guidelines

Internal Appeals Process

You have 65 days from denial to file an internal appeal with Humana. Submit:

  • Appeal request form
  • Original denial letter
  • Additional supporting documentation
  • Provider statement of medical necessity

Pennsylvania External Review

After exhausting internal appeals, Pennsylvania residents can request independent external review through the Pennsylvania Insurance Department.

Success Rate: Approximately 50% of external reviews overturn insurer denials Timeline: 45 days standard, 72 hours expedited Cost: Free to consumers Deadline: 4 months from final internal denial

From our advocates: We've seen cases where the key difference was organizing all lab values chronologically and highlighting the progression of kidney function decline. Insurance reviewers need to see the story of why Filspari is necessary now, not just that the patient has IgA nephropathy.

Costs and Financial Assistance

Manufacturer Support

Travere Therapeutics Total Care offers patient assistance programs for eligible individuals.

Medicare Part D Coverage

With the 2025 out-of-pocket maximum of $2,100, Humana members pay nothing for covered drugs after reaching this threshold.

When to Escalate

Contact the Pennsylvania Insurance Department Consumer Services Bureau at 1-877-881-6388 if:

  • Humana exceeds decision timelines
  • You believe the denial violates coverage rules
  • You need help navigating the external review process

Renewal and Re-authorization

Filspari typically requires annual re-authorization. Start the renewal process 60 days before your current authorization expires. Include:

  • Updated lab values
  • Treatment response documentation
  • Continued medical necessity justification
  • Quarterly liver function test results

Quick Reference Checklist

Before Starting:

  • ☐ Verify Humana plan type and network status
  • ☐ Check formulary coverage for Filspari
  • ☐ Confirm specialty pharmacy requirements

Documentation Needed:

  • ☐ REMS enrollment complete (prescriber and patient)
  • ☐ IgA nephropathy biopsy confirmation
  • ☐ Recent UPCR ≥0.5 g/g and eGFR results
  • ☐ Prior therapy documentation
  • ☐ Baseline liver function tests

Submission:

  • ☐ Complete PA request form
  • ☐ Submit via portal or fax to 877-486-2621
  • ☐ Document reference number and submission date
  • ☐ Follow up within 5 business days

If Denied:

  • ☐ File internal appeal within 65 days
  • ☐ Consider peer-to-peer review
  • ☐ Request Pennsylvania external review if needed
  • ☐ Contact PID Consumer Services for help

Frequently Asked Questions

How long does Humana prior authorization take for Filspari in Pennsylvania? Standard requests take up to 7 days; expedited requests are decided within 72 hours.

What if Filspari isn't on my Humana formulary? Request a formulary exception with medical necessity documentation. Your prescriber must demonstrate why covered alternatives aren't suitable.

Can I get an expedited appeal if my kidney function is declining rapidly? Yes, request expedited review if delay could jeopardize your health. Both Humana and Pennsylvania external review offer 72-hour timelines for urgent cases.

Does the REMS program cost anything? No, REMS enrollment is free, but you must complete quarterly monitoring visits and lab tests.

What happens if I start Filspari while my appeal is pending? You'll pay full cost initially, but if your appeal succeeds, Humana must provide retroactive coverage.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by crafting evidence-backed rebuttals aligned to each plan's specific policies. The platform streamlines the prior authorization process by identifying denial reasons and generating targeted responses with the right clinical evidence and procedural requirements.

Getting Filspari covered requires persistence and proper documentation, but with the right approach and Pennsylvania's strong patient protections, most medically appropriate requests are ultimately approved. Don't give up after an initial denial—the appeals process exists to ensure patients get the treatments they need.

Sources and Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified professionals for insurance matters. Coverage policies and procedures may change; verify current requirements with your insurer and state regulators.

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