By Counterforce Health Team in Filspari (sparsentan) —

Resources to Get Filspari (sparsentan) Approved with UnitedHealthcare in Pennsylvania: Forms, Portals & Contacts

Quick Start: Get Filspari Covered by UnitedHealthcare in Pennsylvania

Fastest Path: Submit prior authorization through UnitedHealthcare's provider portal at uhcprovider.com with complete IgA nephropathy documentation including renal biopsy, eGFR ≥30 mL/min/1.73 m², and evidence of ACE inhibitor or ARB therapy. Most authorizations complete within 24 hours when documentation is complete. If denied, you have 180 days for internal appeals, followed by Pennsylvania's new external review program with a 50% overturn rate. First step today: Verify your plan type (commercial vs. self-funded) and gather your renal biopsy report and recent lab values.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Online Access
  4. Fax Numbers & Mailing Addresses
  5. OptumRx Specialty Pharmacy Setup
  6. Support Lines & Case Management
  7. Pennsylvania Appeals & External Review
  8. When to Update Your Resources

1. Verify Your Plan & Find the Right Forms

Before starting your Filspari authorization, confirm your specific UnitedHealthcare plan type. This determines which forms and processes apply to you.

Plan Types in Pennsylvania:

  • Commercial/Employer Plans: Use standard UnitedHealthcare PA forms
  • Medicare Advantage: Follow Medicare-specific timelines and appeals
  • Medicaid/CHIP: Pennsylvania Community Plan requirements
  • Self-Funded Employer Plans: Limited to internal appeals only
Tip: Check your insurance card for "UnitedHealthcare" vs. "UnitedHealth Community Plan" to identify your plan category.

Coverage at a Glance:

Requirement Details Where to Find It Source
PA Required Yes, all plan types UHC Provider Portal PA Notification
Formulary Tier Tier 3-4 Specialty Plan formulary documents Coverage Policies
Step Therapy ACE inhibitor or ARB required first PA Medical Necessity form PA Requirements
Quantity Limits 1 unit (30-day supply) Formulary restrictions Policy Documents
Authorization Duration 12 months initial Reauthorization required PA Guidelines

2. Prior Authorization Forms & Requirements

UnitedHealthcare requires comprehensive documentation for Filspari approval. All criteria must be met for initial authorization.

Required Clinical Documentation

Diagnosis Requirements:

  • Primary IgA nephropathy confirmed by renal biopsy
  • Patient at risk for disease progression
  • eGFR ≥ 30 mL/min/1.73 m²

Step Therapy Documentation:

  • Current or prior maximized stable dose of ACE inhibitor or ARB
  • Documentation of therapy failure, intolerance, or contraindication
  • Evidence that RAAS inhibitor will be discontinued before starting Filspari

Additional Requirements:

  • Prescription by or in consultation with a nephrologist
  • Documentation of failed 30-day trials (or contraindication) to:
    • Glucocorticoids
    • SGLT2 inhibitors
    • Vanrafia (if applicable)

Medical Necessity Letter Checklist

Your nephrologist should include these elements in the medical necessity letter:

✓ Problem Statement: Primary IgA nephropathy with risk of progression
✓ Prior Treatments: ACE inhibitor/ARB therapy details and outcomes
✓ Clinical Rationale: Why Filspari is appropriate for this patient
✓ Guideline Citations: Reference to FDA labeling and nephrology guidelines
✓ Dosing Plan: Once-daily oral administration
✓ Monitoring Plan: Quarterly liver function tests per REMS requirements

3. Submission Portals & Online Access

UnitedHealthcare Provider Portal

Access: uhcprovider.com
Authentication: One Healthcare ID with passkey, authenticator app, or password + SMS
Support: 855-819-5909 for login issues

Portal Features:

  • Submit and track prior authorizations
  • Upload medical records via Document Library
  • Check authorization status
  • Submit appeals and supporting documentation
Note: Email authentication is no longer available. Ensure you have a recovery code stored securely.

Processing Timelines

  • Standard PA: Up to 15 business days
  • Complete Documentation: Most processed within 24 hours
  • Expedited/Urgent: 72 hours for time-sensitive cases
  • Portal Hours: Monday-Friday 5 AM-10 PM PST, Saturday 6 AM-3 PM PST

4. Fax Numbers & Mailing Addresses

UnitedHealthcare Appeals & PA Contacts

Prior Authorization:

  • Submit via provider portal (recommended)
  • Specific fax numbers vary by plan type—check your denial letter

Internal Appeals:

  • General Provider Appeals Fax: 801-994-1261 (Medicaid/CHP+)
  • Commercial/Medicare: Use contact information in your specific denial letter
  • Online Submission: Strongly recommended through provider portal
Important: Always use the contact information provided in your denial letter for the fastest response, as details vary by plan type.

Pennsylvania Insurance Department (External Review)

Bureau of Health Coverage Access, Administration, and Appeals:

  • Address: 1311 Strawberry Square, Harrisburg, PA 17120
  • Phone: (717) 787-4192 or 1-888-466-2787
  • Fax: (717) 787-8555
  • Email: [email protected]
  • Consumer Hotline: 1-877-881-6388

5. OptumRx Specialty Pharmacy Setup

Filspari requires dispensing through UnitedHealthcare's specialty pharmacy network. Prescriptions do not automatically transfer.

Transfer Process

  1. Initiate Transfer: Call 1-888-341-8579 or register at specialty.optumrx.com
  2. OptumRx Actions: Contacts your doctor and handles prescription transfer
  3. Prior Authorization: Existing PA with 2024+ term date transfers with 1-month grace period
  4. New PA Required: Provider must complete new authorization by end of grace period

Onboarding Steps

  • Register for OptumRx specialty services
  • Provide insurance information and prescription details
  • Confirm delivery address and preferred contact method
  • Schedule initial consultation with specialty pharmacist

6. Support Lines & Case Management

Member Support

UnitedHealthcare Member Services:

  • Phone: Number on back of insurance card
  • Hours: Vary by plan type
  • What to Ask: Prior authorization status, appeal deadlines, formulary tier

Provider Support

Provider Services:

  • Portal Support: 855-819-5909
  • Clinical Support: Available through provider portal
  • Prior Authorization Staff: Monday-Friday 5 AM-10 PM PST

Case Management

For complex cases, request assignment to a case manager who can:

  • Coordinate between departments
  • Track authorization progress
  • Facilitate peer-to-peer reviews
  • Assist with urgent/expedited requests

7. Pennsylvania Appeals & External Review

Pennsylvania launched a new state-run external review program in January 2024 with significant patient success rates.

Internal Appeals Process

Timeline: 180 days from denial date
Levels: 1-2 internal appeal levels
Expedited: Available for urgent medical situations
Submission: Provider portal recommended

Pennsylvania External Review

Eligibility: After exhausting internal appeals (self-funded plans excluded)
Timeline: 4 months from final internal denial
Success Rate: Approximately 50% of appeals overturned in 2024
Process: Independent review organization evaluates case

External Review Steps:

  1. Complete all UnitedHealthcare internal appeals
  2. Obtain Final Adverse Benefit Determination letter
  3. File external review request within 4 months
  4. Submit via Pennsylvania Insurance Department website or mail/fax
  5. Provide additional documentation within 15 days if needed

Timelines:

  • Standard Review: 45 days from IRO assignment
  • Expedited Review: 72 hours for urgent cases
From Our Advocates: In complex cases involving rare medications like Filspari, we've seen success when patients organize all clinical documentation chronologically and include a clear timeline of prior treatments. This composite approach helps reviewers quickly understand the medical necessity and often leads to faster approvals.

8. When to Update Your Resources

Healthcare policies and contact information change frequently. Update your resources:

Quarterly Checks

  • Review UnitedHealthcare formulary updates
  • Verify portal access and authentication methods
  • Check for new prior authorization requirements

Annual Reviews

  • Confirm specialty pharmacy network participation
  • Review Pennsylvania external review procedures
  • Update emergency contact information

After Plan Changes

  • New employer or plan enrollment
  • Medicare/Medicaid eligibility changes
  • Address or provider changes

FAQ: Common Questions About Filspari Coverage

How long does UnitedHealthcare PA take in Pennsylvania?
Most complete requests process within 24 hours; standard timeline is up to 15 business days.

What if Filspari is non-formulary on my plan?
Request a formulary exception with medical necessity documentation and evidence of failed alternatives.

Can I request an expedited appeal?
Yes, if delay could seriously jeopardize your health. Provide supporting medical documentation.

Does step therapy apply if I've tried treatments outside Pennsylvania?
Yes, document all prior therapies regardless of location, including reasons for failure or intolerance.

What happens if Pennsylvania external review approves my case?
UnitedHealthcare must provide coverage immediately and reimburse any out-of-pocket costs incurred during appeals.

Getting Additional Help

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements. For complex cases involving specialty medications like Filspari, Counterforce Health can help patients and clinicians navigate the prior authorization process more effectively.

For additional assistance in Pennsylvania:

  • Pennsylvania Health Law Project: Free legal assistance for health insurance issues
  • Pennie Consumer Hotline: Support for marketplace plan members
  • Patient Advocate Foundation: National organization providing case management services

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for the most current requirements and procedures. Coverage decisions are made by your insurance plan based on your specific policy terms and clinical circumstances.

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