By Counterforce Health Team in Filspari (sparsentan) —

Lowering Out-of-Pocket Costs for Filspari (sparsentan) with Blue Cross Blue Shield in Illinois: Complete Coverage and Savings Guide

Answer Box: Getting Filspari Covered by Blue Cross Blue Shield in Illinois

Filspari (sparsentan) requires prior authorization from Blue Cross Blue Shield of Illinois and is classified as a specialty drug on Tier 5 or 6. To get coverage approved:

  1. Submit prior authorization through your prescriber using BCBSIL's clinical review process (72-hour standard review)
  2. Enroll in REMS program and complete quarterly liver function tests as required by FDA
  3. Use specialty pharmacy (Accredo or CVS Specialty) for dispensing - retail pharmacies cannot fill Filspari

First step today: Contact your prescriber to initiate the prior authorization and REMS enrollment simultaneously. Commercial insurance patients may qualify for $0 copay through Travere TotalCare.

Table of Contents

  1. What Drives Filspari Costs
  2. Investigating Your Benefits
  3. Assistance Options
  4. Requesting Tier Exceptions
  5. Specialty Pharmacy Requirements
  6. Appeals Process
  7. Annual Renewal Planning
  8. Scripts for Key Conversations

What Drives Filspari Costs

Understanding your Blue Cross Blue Shield of Illinois (BCBSIL) benefit design helps you navigate Filspari's high out-of-pocket costs effectively.

Specialty Drug Tiering

Filspari sits on Tier 5 or 6 in most BCBSIL plans, meaning the highest cost-sharing level. While exact copays vary by plan design, specialty drugs typically require:

  • Percentage coinsurance (often 20-50% of drug cost) rather than flat copays
  • Deductible application before coinsurance kicks in
  • Out-of-pocket maximum protection (but you'll pay full coinsurance until you reach it)
Note: With Filspari's list price around $10,000 monthly, even 20% coinsurance means $2,000+ out-of-pocket per month without assistance.

Prior Authorization Requirements

BCBSIL requires prior authorization for Filspari, evaluating:

  • Confirmed IgA nephropathy diagnosis with appropriate specialist documentation
  • REMS program enrollment for hepatotoxicity monitoring
  • Contraindication screening (pregnancy, liver disease, drug interactions)
  • Clinical necessity based on disease progression risk

Investigating Your Benefits

Before starting the approval process, gather specific information about your BCBSIL coverage.

Key Questions for BCBSIL Customer Service

Call the number on your insurance card and ask:

  1. "What tier is Filspari on my specific plan?"
  2. "What's my specialty drug coinsurance percentage?"
  3. "Do I need to meet my deductible first?"
  4. "What's my out-of-pocket maximum for 2024?"
  5. "Which specialty pharmacy must I use?"

Information to Record

  • Plan name and group number
  • Specialty drug benefit details
  • Prior authorization requirements
  • Approved specialty pharmacy network
  • Appeals process and timelines
Tip: Use your MyPrime member portal to access your specific formulary and benefit details online.

Assistance Options

Multiple programs can significantly reduce your Filspari costs, depending on your insurance type.

Manufacturer Copay Program

Travere TotalCare Copay Card offers the most substantial savings for commercially insured patients:

  • $0 monthly copay for eligible patients
  • Commercial insurance requirement (excludes Medicare, Medicaid, TRICARE)
  • Annual maximum benefit applies
  • Enrollment required through prescriber using Patient Start Form

Contact: 1-833-345-7727 or visit Travere TotalCare

Foundation Grants

IgA Nephropathy Foundation Patient Aid Grant:

  • Covers out-of-pocket medical costs including medication copays
  • Available to all U.S. residents with physician-confirmed IgAN diagnosis
  • Membership required before applying
  • Application describes financial impact and need

HealthWell Foundation IgA Nephropathy Fund:

  • Average $3,000 per 12-month period
  • Income eligibility up to 500% Federal Poverty Level
  • Covers prescription copays and insurance premiums
  • Fund status varies - check availability before applying

Case Management Support

Specialty pharmacies provide dedicated case managers who:

  • Navigate prior authorization processes
  • Coordinate benefit investigations
  • Identify additional assistance programs
  • Manage REMS compliance requirements

Requesting Tier Exceptions

When standard coverage results in unaffordable costs, formulary exceptions can reduce your tier placement.

When to Request Exceptions

Consider a tier exception if:

  • Your specialty drug coinsurance exceeds $500 monthly
  • Lower-tier alternatives are contraindicated
  • You've failed step therapy requirements on other drugs
  • Financial hardship prevents access to treatment

Documentation Requirements

Submit through your prescriber using BCBSIL Prescription Drug Formulary Exception Form:

Required elements:

  • Detailed prescriber letter explaining medical necessity
  • Documentation of failed alternatives or contraindications
  • Patient diagnosis with ICD-10 codes
  • Clinical records supporting the request
  • Prior authorization history if applicable

Submission Process

  • Fax: 877-243-6930 (Prime Therapeutics Clinical Review)
  • Online: MyPrime portal or CoverMyMeds
  • Timeline: 72-hour standard review, 24-hour expedited
Note: Tier exceptions are evaluated based on medical necessity, not just cost concerns. Focus your request on clinical factors.

Specialty Pharmacy Requirements

Filspari must be dispensed through BCBSIL's specialty pharmacy network - retail pharmacies cannot fill this prescription.

Network Options

CVS Specialty and Accredo are primary specialty pharmacies for BCBSIL members. These pharmacies handle:

  • Prior authorization coordination
  • REMS program compliance
  • Home delivery scheduling
  • Insurance benefit verification
  • Ongoing clinical support

Coordination Process

  1. Prescriber submits prescription and prior authorization simultaneously
  2. Specialty pharmacy contacts patient for benefit verification
  3. REMS enrollment completed if not already done
  4. Delivery scheduled typically within 2-3 business days
  5. Follow-up coordination for refills and lab monitoring
Important: Answer calls from your specialty pharmacy promptly to avoid delays in treatment initiation.

Appeals Process

When prior authorization is denied, Illinois provides strong appeal rights through multiple levels of review.

Internal Appeals

Timeline: File within 60 days of denial notice Decision: 30 days standard, 72 hours expedited Submission: Use BCBSIL internal appeal form via MyPrime portal

External Review (Illinois-Specific)

Illinois' Health Carrier External Review Act provides independent physician review:

Timeline: Request within 30 days of final internal denial (shorter than most states) Process: Illinois Department of Insurance coordinates Independent Review Organization Decision: 5 business days after IRO receives complete file Cost: Free to consumers

Contact: Illinois Department of Insurance at 877-527-9431

Critical: Illinois' 30-day external review deadline is shorter than many states - don't delay if your internal appeal is denied.

Required Appeal Documentation

  • Complete denial letter and internal appeal decision
  • Additional clinical evidence not previously submitted
  • Updated prescriber letter addressing denial reasons
  • Relevant medical records and lab results
  • Counterforce Health can help generate targeted appeal letters that address specific denial reasons with evidence-backed rebuttals.

Annual Renewal Planning

Plan ahead for coverage changes that affect Filspari access and costs.

What Changes Annually

  • Formulary placement and tier assignment
  • Prior authorization criteria
  • Specialty pharmacy network
  • Copay assistance program terms
  • Out-of-pocket maximums and deductibles

Renewal Checklist

October-November:

  • Review next year's formulary for Filspari placement
  • Compare plan options during open enrollment
  • Confirm specialty pharmacy network continuity

December:

  • Renew manufacturer copay assistance if eligible
  • Update foundation grant applications
  • Coordinate with specialty pharmacy for seamless transition

January:

  • Verify new year's benefits took effect correctly
  • Confirm prior authorization remains active
  • Check that REMS enrollment continues

Scripts for Key Conversations

Use these conversation guides to get the information and approvals you need.

Calling BCBSIL Customer Service

"Hi, I need information about coverage for Filspari, spelled F-I-L-S-P-A-R-I. Can you tell me what tier it's on for my plan [give plan name], what my coinsurance percentage is, and which specialty pharmacy I need to use?"

Prescriber Office Discussion

"I need prior authorization for Filspari. Can we also complete the REMS enrollment at the same time? I'd like to apply for the manufacturer copay program too - do you have the Patient Start Form?"

Specialty Pharmacy Coordination

"I'm starting Filspari and want to understand the process. Can you verify my benefits, coordinate the prior authorization with my doctor, and help me apply for copay assistance?"

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Medical necessity review required MyPrime portal or prescriber 72 hours standard
REMS Enrollment FDA safety program for liver monitoring Prescriber or specialty pharmacy Same day
Specialty Pharmacy Must use network specialty pharmacy BCBSIL customer service 2-3 days delivery
Tier 5/6 Placement Highest cost-sharing level Plan formulary document Varies by plan

From Our Advocates

We've seen patients successfully reduce their Filspari costs from $2,000+ monthly to under $50 by combining manufacturer copay assistance with formulary exception requests. The key is starting all applications simultaneously - prior authorization, REMS enrollment, and copay program - rather than tackling them sequentially. This composite experience reflects multiple successful cases but outcomes vary by individual circumstances.

FAQ

How long does BCBSIL prior authorization take for Filspari? Standard review takes 72 hours; expedited review for urgent cases takes 24 hours. Your prescriber can request expedited review if delays would jeopardize your health.

What if Filspari isn't on my BCBSIL formulary? Request a formulary exception through your prescriber using clinical documentation showing medical necessity and failed alternatives. The 72-hour review timeline applies.

Can I get expedited appeals in Illinois? Yes, both internal appeals and external reviews can be expedited if standard timelines would seriously jeopardize your health. Request expedited processing when filing.

Does the copay card work with all BCBSIL plans? The Travere TotalCare copay card works with commercial BCBSIL plans but excludes government-sponsored coverage like Medicare Advantage or Medicaid plans.

What happens if I move from Illinois to another state? Your BCBSIL coverage may continue if it's a multi-state plan, but appeal rights and external review processes will follow your new state's laws and timelines.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always verify current requirements with your insurer and healthcare providers. For personalized assistance with prior authorizations and appeals, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.