By Counterforce Health Team in Filspari (sparsentan) —

How to Get Filspari (Sparsentan) Covered by UnitedHealthcare in Ohio: Complete Guide with Forms, Appeals, and State Resources

Quick Answer: Getting Filspari (Sparsentan) Covered by UnitedHealthcare in Ohio

Fastest path to approval: Submit prior authorization through UnitedHealthcare's provider portal with complete IgA nephropathy documentation, REMS enrollment, and evidence of failed glucocorticoids/SGLT2 inhibitors. Standard reviews complete in 72 hours; expedited in 24 hours. If denied, you have 180 days for internal appeals, then Ohio's external review through the Department of Insurance (1-800-686-1526). Start today: Verify your plan requires PA and gather kidney biopsy results, eGFR ≥30, and prior therapy documentation.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Online Tools
  4. Specialty Pharmacy Requirements
  5. Common Denial Reasons and Solutions
  6. Appeals Process in Ohio
  7. State Resources and Consumer Help
  8. Cost Assistance Programs
  9. FAQ

Start Here: Verify Your Plan and Coverage

Before starting your Filspari (sparsentan) approval process, confirm these basics:

Check Your Plan Type: UnitedHealthcare requires prior authorization for all Filspari prescriptions through their OptumRx specialty pharmacy network. This applies to commercial plans, Medicare Advantage, and most employer-sponsored coverage in Ohio.

Verify Formulary Status: Filspari is typically classified as Tier 3-4 specialty coverage with quantity limits of one 30-day supply per authorization period.

Note: If you have a self-funded employer plan, your appeals may follow federal ERISA rules rather than Ohio state regulations. Contact your HR department to confirm.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all requests UnitedHealthcare Provider Portal
Formulary Tier Tier 3-4 Specialty Plan formulary document
Step Therapy Must fail glucocorticoids, SGLT2 inhibitors, Vanrafia PA Medical Necessity Form
Quantity Limits 30-day supply maximum OptumRx specialty pharmacy
REMS Enrollment Required before dispensing FilspariREMS.com
Appeals Deadline 180 days from denial Ohio Department of Insurance

Required Forms and Documentation

Primary Prior Authorization Form

UnitedHealthcare Medical Necessity Form for Filspari: Download the current version from the UnitedHealthcare provider portal. This form requires:

  • Diagnosis confirmation: Primary IgA nephropathy confirmed by renal biopsy
  • Risk assessment: Documentation of disease progression risk
  • Kidney function: eGFR ≥30 mL/min/1.73 m²
  • Prior therapy documentation: 30-day trials and failures of required medications
  • Prescriber qualification: Nephrologist prescription or consultation

Essential Clinical Documentation

  1. Kidney biopsy report confirming primary IgA nephropathy
  2. Recent labs showing eGFR ≥30 mL/min/1.73 m² and proteinuria levels
  3. Prior therapy records documenting failures, contraindications, or intolerance to:
    • Glucocorticoids
    • SGLT2 inhibitors
    • Vanrafia (budesonide delayed-release)
  4. RAAS therapy documentation showing maximized stable ACE inhibitor or ARB dose
  5. REMS enrollment confirmation from prescriber

Submission Portals and Online Tools

UnitedHealthcare Provider Portal

Primary submission method: UHCProvider.com

  • Sign in with One Healthcare ID
  • Select "Prior Authorizations" from the main menu
  • Upload completed forms and supporting documentation
  • Track status and receive notifications

Timeline: Standard requests reviewed within 72 hours; expedited requests within 24 hours when documentation is complete.

Alternative Submission Methods

  • Provider phone line: 888-397-8129
  • Pharmacy prior authorization help: 1-833-491-0344
  • OptumRx specialty services: 1-888-341-8579
Tip: Submit through the online portal when possible—it provides real-time status updates and faster processing than fax or mail submissions.

Specialty Pharmacy Requirements

OptumRx Network Requirement

Filspari must be dispensed through UnitedHealthcare's contracted specialty pharmacy network, primarily OptumRx. Coverage is not available for prescriptions filled outside this network.

REMS Program Compliance

Critical requirement: All patients must be enrolled in the FILSPARI REMS Program before dispensing. Recent changes (effective August 2025) simplified monitoring:

  • Quarterly liver function tests (ALT, AST, bilirubin) required every 3 months
  • Embryo-fetal toxicity monitoring removed from REMS requirements
  • Prescriber certification required through FilspariREMS.com

Prescription Transfer Process

  1. Call OptumRx at 1-888-341-8579 to initiate transfer
  2. Register at specialty.optumrx.com for account management
  3. Confirm REMS enrollment and quarterly lab scheduling
  4. Verify prior authorization approval before first fill

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Missing REMS enrollment Submit prescriber REMS certification and patient enrollment confirmation
Insufficient prior therapy trials Provide detailed records of 30-day glucocorticoid and SGLT2 inhibitor failures
eGFR below 30 Submit recent labs confirming eGFR ≥30 mL/min/1.73 m²
Non-nephrologist prescriber Include nephrologist consultation notes or transfer prescription
Missing biopsy confirmation Submit pathology report confirming primary IgA nephropathy
Quantity limit exceeded Request 30-day supply only; coordinate refill timing with quarterly labs

Clinician Corner: Medical Necessity Letter Checklist

When appealing a denial, include these elements in your medical necessity letter:

✓ Primary diagnosis: IgA nephropathy confirmed by renal biopsy with specific pathology findings
✓ Disease progression risk: Current proteinuria levels, eGFR trends, and risk factors
✓ Prior therapy failures: Specific medications tried, duration, outcomes, and reasons for discontinuation
✓ Clinical rationale: Why Filspari's dual mechanism (endothelin/angiotensin receptor antagonism) is appropriate
✓ Monitoring plan: Quarterly liver function tests and REMS compliance procedures
✓ Supporting literature: FDA approval data and clinical trial evidence from the manufacturer's prescribing information

Appeals Process in Ohio

Internal Appeals with UnitedHealthcare

Timeline: File within 21 calendar days of denial notice

  1. First-level internal appeal
    • Decision within 5-10 business days (standard)
    • Decision within 72 hours (urgent cases)
    • Submit through provider portal or member services
  2. Second-level internal appeal (if available)
    • Same timelines as first level
    • May include peer-to-peer review option

Ohio External Review Process

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

Key details:

  • Deadline: 180 days from final internal denial
  • Cost: No charge to patient
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Contact: Ohio Department of Insurance at 1-800-686-1526

How to file:

  1. Call the consumer hotline at 1-800-686-1526 for the External Review Request Form
  2. Submit request to your health plan (they notify the Ohio DOI)
  3. Independent Review Organization (IRO) conducts medical review
  4. Decision is binding on UnitedHealthcare
Important: Even if UnitedHealthcare claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

State Resources and Consumer Help

Ohio Department of Insurance Consumer Services

  • Consumer hotline: 1-800-686-1526
  • Website: insurance.ohio.gov
  • Services: External review assistance, complaint filing, coverage questions

Additional Ohio Resources

  • UHCAN Ohio (Universal Health Care Action Network): Consumer advocacy and appeal assistance
  • Ohio Senior Health Insurance Information Program (OSHIIP): Medicare-specific help for seniors
  • Ohio Department of Medicaid: For Medicaid managed care appeals and state fair hearings

Cost Assistance Programs

Manufacturer Support

Travere Therapeutics Patient Support: Contact the manufacturer for potential copay assistance and financial hardship programs. Eligibility varies by insurance type and income level.

Foundation Resources

Research patient assistance foundations that support rare kidney disease treatments. Many foundations provide grants for medication copays and related expenses.

Note: Manufacturer copay cards typically cannot be used with government insurance (Medicare, Medicaid) but may help with commercial coverage.

When to Escalate

Contact the Ohio Department of Insurance if:

  • UnitedHealthcare misses appeal deadlines
  • You're told external review isn't available when it should be
  • The insurer requests inappropriate documentation
  • You experience delays in the external review process

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to create targeted, evidence-backed rebuttals. Their platform helps patients and providers navigate complex prior authorization requirements and appeal processes for specialty medications like Filspari.

FAQ

How long does UnitedHealthcare prior authorization take for Filspari in Ohio? Standard reviews complete within 72 hours; expedited reviews within 24 hours when all required documentation is submitted through the provider portal.

What if Filspari isn't on my UnitedHealthcare formulary? Filspari is typically covered as a Tier 3-4 specialty drug. If it appears non-formulary, request a formulary exception with medical necessity documentation.

Can I request an expedited appeal in Ohio? Yes, urgent appeals are processed within 72 hours if a delay would seriously jeopardize your health. Your doctor must document the urgency.

Does step therapy apply if I tried required medications outside Ohio? Yes, prior therapy documentation from any location counts toward step therapy requirements, as long as you have complete medical records.

What happens if I miss the 180-day appeals deadline in Ohio? The deadline is strict, but exceptional circumstances may warrant consideration. Contact the Ohio Department of Insurance immediately to discuss your situation.

How do I transfer my Filspari prescription to OptumRx specialty pharmacy? Call OptumRx at 1-888-341-8579 and register at specialty.optumrx.com. Ensure your prior authorization and REMS enrollment are current before transfer.

Can I appeal to Ohio if I have an employer self-funded plan? Self-funded plans follow federal ERISA rules, not Ohio state appeals. However, many voluntarily use external review processes. Check with your HR department.

What if UnitedHealthcare denies my external review eligibility? The Ohio Department of Insurance can independently determine eligibility and order an external review regardless of the insurer's position. Call 1-800-686-1526.

This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. For personalized guidance, consult with your healthcare provider and contact Counterforce Health for specialized appeals assistance. Always verify current forms, deadlines, and contact information with official sources before submitting requests.

Sources & Further Reading

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