Answer Box: Getting Filspari (sparsentan) Covered by Humana in Virginia

Humana requires prior authorization for Filspari (sparsentan) with specific clinical criteria: biopsy-confirmed IgA nephropathy, UPCR ≥0.5 g/g, inadequate response to ACE inhibitor/ARB therapy for ≥3 months, and mandatory REMS enrollment. Submit PA via Humana's provider portal or fax to 877-486-2621. If denied, Virginia residents have 65 days to appeal internally, then 120 days for external review through the State Corporation Commission Bureau of Insurance. First step today: Verify your Humana plan covers specialty drugs and enroll in FILSPARI REMS at filsparirems.com.

Table of Contents

1. Who Should Use This Guide
2. Member & Plan Basics
3. Clinical Criteria Checklist
4. REMS Documentation Requirements
5. Prior Authorization Submission
6. After Submission: Tracking & Follow-up
7. Appeals Process in Virginia
8. Common Denial Reasons & Solutions
9. Cost Savings & Patient Support
10. Quick Reference Checklist

Who Should Use This Guide

This comprehensive checklist is designed for Virginia residents with Humana Medicare Advantage or Part D coverage who need Filspari (sparsentan) for IgA nephropathy. You'll also find this helpful if you're a healthcare provider submitting prior authorization requests or appealing denials for patients.

Expected outcome: Following this guide increases your chances of first-time approval and provides a clear roadmap for appeals if needed. With proper documentation, many patients successfully obtain coverage within 7-14 days.

Member & Plan Basics

Verify Your Coverage Foundation

Before starting the prior authorization process, confirm these essentials:

• Active Humana coverage: Check your member ID card shows current effective dates
• Plan type: Medicare Advantage (Part C) or standalone Part D prescription drug plan
• Specialty pharmacy benefits: Filspari requires specialty pharmacy dispensing through Humana's network
• Deductible status: Verify if you've met your annual deductible (affects out-of-pocket costs)

Tip: Call Humana member services at 1-800-HUMANA (1-800-486-2621) to confirm Filspari is covered under your specific plan's formulary.

Clinical Criteria Checklist

Required Documentation for Approval

Humana's prior authorization criteria for Filspari are specific and must be thoroughly documented:

Requirement	Documentation Needed	Notes
Primary IgA nephropathy diagnosis	Kidney biopsy report with pathologist confirmation	Must exclude secondary causes
Proteinuria threshold	UPCR ≥0.5 g/g (recent, within 3 months)	Some plans require ≥1.0 g/g; verify your specific criteria
eGFR documentation	Current estimated glomerular filtration rate	Baseline kidney function assessment
Prior therapy failure	≥3 months of maximally tolerated ACE inhibitor or ARB	Document specific medications, doses, duration, and outcomes
Specialist involvement	Nephrologist consultation and ongoing care	Demonstrates appropriate specialty management
Liver function tests	Baseline ALT, AST, and bilirubin	Required before REMS enrollment

Step Therapy Requirements

Most Humana plans require documented inadequate response to:

• ACE inhibitors (e.g., lisinopril, enalapril) at ≥50% of maximum labeled dose
• ARB therapy (e.g., losartan, valsartan) if ACE inhibitors are contraindicated or not tolerated
• Duration: Minimum 12 weeks of therapy at optimal doses

Document specific reasons for inadequacy: persistent proteinuria, disease progression, or intolerance with specific symptoms.

REMS Documentation Requirements

The FILSPARI REMS program underwent significant updates in 2025, simplifying requirements while maintaining essential safety monitoring.

Current REMS Elements (Updated 2025)

Hepatotoxicity monitoring remains the core requirement:

• Enrollment: All prescribers, patients, and pharmacies must enroll at filsparirems.com
• Liver function monitoring:
  • Baseline: Before starting treatment
  • Monthly for first 12 months
  • Quarterly (every 3 months) thereafter
• Safety thresholds: Avoid initiation if ALT/AST >3x upper limit of normal

Important Update: As of August 2025, embryo-fetal toxicity (EFT) monitoring requirements were removed from the REMS program. Pregnancy contraindication is now addressed through labeling alone.

REMS Submission Process

1. Enroll all parties at filsparirems.com before PA submission
2. Upload baseline labs to REMS portal
3. Include REMS confirmation in your prior authorization packet
4. Coordinate with specialty pharmacy for ongoing lab verification

Contact Travere TotalCare at 1-833-345-7727 for REMS enrollment assistance and coordination support.

Prior Authorization Submission

Step-by-Step Submission Process

Step 1: Gather Required Forms

• Complete "Request for Medicare Prescription Drug Coverage Determination" form
• Prepare clinical documentation packet (see checklist below)

Step 2: Submit via Preferred Method

• Fax: 877-486-2621 (include reference number for tracking)
• Online: Humana provider portal (log in required)
• Phone: 1-866-488-5995 (pharmacy PA line for urgent cases)

Step 3: Include Complete Documentation

• Biopsy report with IgA nephropathy confirmation
• Recent UPCR and eGFR lab results
• Prior ACE inhibitor/ARB therapy records with outcomes
• REMS enrollment confirmation
• Prescriber's letter of medical necessity

Medical Necessity Letter Components

Your nephrologist's letter should address:

• Clinical presentation: Specific IgA nephropathy features and risk factors
• Prior treatments: Detailed history of ACE inhibitor/ARB therapy with specific drugs, doses, duration, and outcomes
• Treatment rationale: Why Filspari is medically necessary based on FDA labeling and clinical guidelines
• Monitoring plan: Commitment to REMS compliance and quarterly liver function monitoring
• Treatment goals: Expected clinical outcomes (e.g., proteinuria reduction, kidney function preservation)

After Submission: Tracking & Follow-up

Timeline Expectations

• Standard review: 7 calendar days
• Expedited review: 72 hours (for urgent medical situations)
• Status checks: Use Humana provider portal or call with reference number

What to Track

Document all interactions:

• Submission date and method
• Reference number (critical for follow-up)
• Representative names and call dates
• Additional information requests
• Decision date and outcome

Pro Tip: If you don't receive a decision within the standard timeline, call immediately. Delays often indicate missing documentation that can be quickly resolved.

Appeals Process in Virginia

Internal Appeals (First Level)

If your initial PA is denied:

• Timeline: 65 days from denial notice to file appeal
• Method: Submit via Humana member portal, mail, or fax
• Include: Original denial letter, new clinical information, prescriber's rebuttal letter

Virginia External Review Process

Virginia residents have strong protections through the State Corporation Commission Bureau of Insurance:

External Review Timeline:

• File within: 120 days of final internal appeal denial
• Standard review: 45 days maximum
• Expedited review: 72 hours for urgent cases

How to File:

1. Complete Form 216-A (External Review Request)
2. Submit to Virginia Bureau of Insurance, State Corporation Commission
3. Include all denial notices, medical records, and supporting documentation
4. No fee required for external review

Contact Information:

• Phone: (804) 371-9740
• Website: scc.virginia.gov/boi (for current forms and submission guidelines)

The external review process assigns an independent medical expert to review your case, with a significant overturn rate for appropriate denials.

Common Denial Reasons & Solutions

Denial Reason	Solution Strategy
Missing REMS enrollment	Submit REMS confirmation from filsparirems.com; coordinate with specialty pharmacy
Insufficient prior therapy	Document specific ACE inhibitor/ARB trials with doses, duration, and clinical outcomes
Lab values don't meet threshold	Verify UPCR ≥0.5 g/g with recent results; request peer-to-peer review if borderline
Non-formulary status	Request formulary exception with medical necessity documentation
Quantity limits exceeded	Provide clinical rationale for prescribed dosing (400mg daily after 14-day titration)

From our advocates: We've seen many initially denied cases succeed on appeal when the prescriber provides a detailed narrative explaining why standard ACE inhibitor/ARB therapy was inadequate despite optimal dosing. Include specific proteinuria levels before, during, and after prior treatments—numbers tell the story payers need to hear.

Cost Savings & Patient Support

Manufacturer Support Programs

Travere TotalCare provides comprehensive support:

• Prior authorization assistance: Dedicated team to help with submissions and appeals
• Financial assistance: Copay support programs for eligible patients
• Clinical coordination: REMS enrollment and lab monitoring support
• Contact: 1-833-345-7727

Additional Resources

• Humana's specialty pharmacy: CenterWell Specialty Pharmacy for coordinated care
• Virginia resources: Contact the Bureau of Insurance for coverage disputes
• Patient advocacy: Counterforce Health helps patients and providers navigate complex prior authorization and appeals processes, turning insurance denials into evidence-backed approvals

Quick Reference Checklist

Before You Start

• Verify active Humana coverage with specialty pharmacy benefits
• Confirm IgA nephropathy diagnosis with biopsy report
• Document UPCR ≥0.5 g/g and current eGFR
• Record prior ACE inhibitor/ARB therapy details (drugs, doses, duration, outcomes)
• Obtain baseline liver function tests

REMS Requirements

• Enroll prescriber at filsparirems.com
• Complete patient enrollment in REMS program
• Coordinate specialty pharmacy enrollment
• Schedule monthly LFT monitoring for first year

Prior Authorization Submission

• Complete Humana PA form
• Attach biopsy report and lab results
• Include prior therapy documentation
• Submit REMS enrollment confirmation
• Provide prescriber's medical necessity letter
• Submit via fax (877-486-2621) or provider portal

After Submission

• Record reference number and submission date
• Track status via portal or phone
• Respond promptly to information requests
• Document all communications

If Denied

• File internal appeal within 65 days
• Consider peer-to-peer review request
• Prepare for Virginia external review if needed (120-day deadline)
• Contact Travere TotalCare for support

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Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies overcome prior authorization challenges by transforming insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned with each payer's requirements, significantly improving approval rates for complex medications like Filspari.

Sources & Further Reading

• Humana Prior Authorization Lists
• FILSPARI REMS Program
• Virginia Bureau of Insurance External Review
• Travere TotalCare Support
• FDA FILSPARI Prescribing Information

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Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical advice. Always consult with your healthcare provider about treatment decisions and follow your specific plan's requirements. Coverage policies can change; verify current requirements with Humana and check the latest REMS program details at filsparirems.com.

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