CurrentCignaPolicy N/A

Filspari (sparsentan) prior authorization — Nephrology coverage criteria

Cigna coverage and prior authorization requirements for Filspari (sparsentan) for treatment of focal segmental glomerulosclerosis (FSGS) and primary immunoglobulin A nephropathy (IgAN), including prescribing, eligibility, and exclusion rules affecting clinicians and pharmacy benefit adjudication.

Policy Summary

PayerCigna

PolicyFilspari (sparsentan) prior authorization — Nephrology coverage criteria

Policy CodePolicy N/A

Change TypeMaterial clinical updates (added FSGSrevised IgAN thresholdscoverage exclusions)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document age, diagnosis confirmation, UPCR/proteinuria, eGFR ≥30, prior ACEi/ARB use for IgAN, and nephrologist involvement.

SourceLink

POLICY UPDATE CHANGES

Focal Segmental Glomerulosclerosis was added as a new condition of approval.

Criterion defining high risk of disease progression for IgAN was revised to require lower proteinuria thresholds (urine protein-to-creatinine ratio ≥ 0.5 g/g OR proteinuria ≥ 0.5 g/day).

Conditions Not Covered: concurrent use with other medications indicated for IgAN (e.g., Fabhalta and Vanrafia) was added.

Approval duration standardized to 1 year for initial and continuation therapy.

2FDA-approved indications covered (FSGS, IgAN)

≥8 yrsMin age (FSGS)

≥18 yrs

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

eGFR ≥30Min renal function

1 yrApproval duration

Coverage Criteria for Filspari (sparsentan)

Focal Segmental Glomerulosclerosis — FDA-Approved Indication

Approve for 1 year if the patient meets ONE of the following (A or B):

FSGS: Initial Therapy (A) or Currently Receiving (B)

Initial Therapy criteria: i. Patient is ≥ 8 years of age; AND ii. Patient has ONE of: a) biopsy confirming the disease OR b) genetic variant associated with the disease; AND iii. Patient does not have nephrotic syndrome; AND iv. UPCR ≥ 1.5 g/g; AND v. eGFR ≥ 30 mL/min/1.73 m²; AND vi. Medication will not be used in combination with any renin-angiotensin-aldosterone system inhibitors (e.g., ACEi or ARB), endothelin receptor antagonists, or aliskiren; AND vii. Prescribed by or in consultation with a nephrologist.Age ≥8; UPCR ≥1.5 g/g; eGFR ≥30
Examples of genetic variants: CD2AP, INF2, LMX1B, NPHS1, NPHS2, TRPC6, WT1, COL4A3-5, APOL1.
Currently Receiving criteria: i. Patient is ≥ 8 years of age; AND ii. Patient has had a response to Filspari (e.g., reduction in UPCR from baseline); AND iii. eGFR ≥ 30 mL/min/1.73 m²; AND iv. Medication is not being used in combination with any RAAS inhibitors, endothelin receptor antagonists, or aliskiren; AND v. Prescribed by or in consultation with a nephrologist.eGFR ≥30
Example of response: reduction in urine protein-to-creatinine ratio from baseline.

Primary Immunoglobulin A Nephropathy (IgAN) — FDA-Approved Indication

Approve for 1 year if the patient meets ONE of the following (A or B):

IgAN: Initial Therapy (A) or Currently Receiving (B)

Initial Therapy criteria: i. Patient is ≥ 18 years of age; AND ii. Diagnosis confirmed by biopsy; AND iii. Patient is at high risk of disease progression defined by BOTH: a) proteinuria ≥ 0.5 g/day OR UPCR ≥ 0.5 g/g; AND b) has received the maximum or maximally tolerated dose of ONE ACEi or ARB for ≥ 12 weeks prior to starting the medication; AND iv. Patient has received ≥ 3 months of optimized supportive care (blood pressure management, lifestyle modification, cardiovascular risk modification) per prescriber; AND v. eGFR ≥ 30 mL/min/1.73 m²; AND vi. Medication will not be used in combination with any RAAS inhibitors, endothelin receptor antagonists, or aliskiren; AND vii. Prescribed by or in consultation with a nephrologist.Proteinuria ≥0.5 g/day or UPCR ≥0.5 g/g; ACEi/ARB ≥12 weeks; eGFR ≥30
Supportive care defined by prescriber.
Currently Receiving criteria: i. Patient is ≥ 18 years of age; AND ii. Diagnosis confirmed by biopsy; AND iii. Patient has had a response to the requested medication (e.g., reduction in UPCR or proteinuria from baseline); AND iv. eGFR ≥ 30 mL/min/1.73 m²; AND v. Medication is not being used in combination with any RAAS inhibitors, endothelin receptor antagonists, or aliskiren; AND vi. Prescribed by or in consultation with a nephrologist.

Requests for Filspari (sparsentan) that propose concurrent administration with other medications indicated for the treatment of immunoglobulin A nephropathy (for example, Fabhalta or Vanrafia) are considered not medically necessary and will be denied. Such combination use is specifically listed in the policy’s Conditions Not Covered.

Combination therapy of Filspari with other IgAN-specific agents is not supported by controlled clinical trial data demonstrating additive efficacy. For this reason, the policy deems use of Filspari in combination with other medications indicated for IgAN as not medically necessary.

Coding, Laboratory & Eligibility Thresholds

Coding guidancemixed

no specific codes listed

Policy references that providers must use the most appropriate codes; document does not enumerate CPT/ICD/HCPCS codes.

Proteinuria / UPCR thresholds — FSGS and IgAN

FSGS entry UPCR thresholdUrine protein-to-creatinine ratio ≥ 1.5 g/g is required for initial FSGS therapy entry.

IgAN high‑risk proteinuria thresholdProteinuria ≥ 0.5 g/day OR urine protein-to-creatinine ratio ≥ 0.5 g/g defines high risk of progression for IgAN.

Nephrotic syndrome exclusion (adults)Nephrotic syndrome defined as current proteinuria > 3.5 g/day excludes FSGS initial therapy.

Nephrotic syndrome exclusion (pediatrics)For patients <18 years, nephrotic syndrome is defined as urine protein-to-creatinine ratio ≥ 2 g/g with serum albumin < 30 g/L (with or without edema) and excludes FSGS initial therapy.

eGFR threshold required for approvals

eGFR requirement

Provider Actions, Documentation & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization is required for Filspari. Approvals are issued for the duration indicated in the criteria (when in months, 1 month = 30 days).

Prior authorization required for prescription benefit coverage of Filspari.
Approvals provided for the duration noted; 1 month = 30 days.

Documentation Required

Specialist Prescribing Requirement

Specialist involvement required. Because of the specialized skills required for evaluation, diagnosis, monitoring of adverse events, and long-term efficacy, Filspari must be prescribed by or in consultation with a physician who specializes in the condition being treated (nephrologist). Document the specialist’s involvement in the medical record and prior authorization request.

Prescription by or in consultation with a nephrologist is required for both FSGS and IgAN indications.

Background

Filspari (sparsentan) is a dual endothelin and angiotensin II receptor antagonist approved to reduce proteinuria in focal segmental glomerulosclerosis and to slow kidney function decline in adults with primary immunoglobulin A nephropathy at risk of progression. Clinical development included trials demonstrating reductions in proteinuria; however, safety considerations (including hepatotoxicity and embryo-fetal risk) and the absence of controlled data for combination regimens underpin coverage limits.

Key Definitions

Nephrotic syndrome — definitions

Adult nephrotic syndrome definitionPresence of nephrotic syndrome is current proteinuria > 3.5 g/day and excludes patients from FSGS initial therapy.

Pediatric nephrotic syndrome definitionFor patients <18 years, nephrotic syndrome is urine protein-to-creatinine ratio ≥ 2 g/g with serum albumin < 30 g/L, with or without edema, and excludes FSGS initial therapy.

Serum albumin thresholdSerum albumin < 30 g/L is part of the pediatric nephrotic syndrome definition.

High risk of disease progression (IgAN) — thresholds and prerequisites

IgAN high‑risk proteinuria thresholdHigh risk of disease progression requires proteinuria ≥ 0.5 g/day OR urine protein-to-creatinine ratio ≥ 0.5 g/g.

Prior ACEi/ARB optimization

Policy Summary

PayerCigna

PolicyFilspari (sparsentan) prior authorization — Nephrology coverage criteria

Policy CodePolicy N/A

Change TypeMaterial clinical updates (added FSGSrevised IgAN thresholdscoverage exclusions)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document age, diagnosis confirmation, UPCR/proteinuria, eGFR ≥30, prior ACEi/ARB use for IgAN, and nephrologist involvement.

SourceLink

On This Page

Examples of response: reduction in urine protein-to-creatinine ratio or proteinuria from baseline.

Estimated glomerular filtration rate (eGFR) ≥ 30 mL/min/1.73 m² is required for approval for both FSGS and IgAN indications.

Continuation therapy eGFRPatients currently receiving therapy must have eGFR ≥ 30 mL/min/1.73 m² to continue treatment.

DocumentationClinical documentation must include measured eGFR to confirm the ≥30 mL/min/1.73 m² threshold.

Age thresholds for FDA indications

FSGS age thresholdPatients must be ≥ 8 years of age for the FSGS indication (initial and continuation criteria reference this minimum age).

IgAN age threshold (initial)Initial therapy for IgAN requires the patient to be ≥ 18 years of age.

IgAN age threshold (continuing therapy)Patients currently receiving Filspari for IgAN must be ≥ 18 years of age to meet continuation criteria.

Document nephrology consultation or that the prescriber is a nephrologist.

Step Therapy

Pre-requisite RAAS Therapy and Supportive Care

RAAS inhibitor and supportive care prerequisites. For IgAN, patients must have received maximum or maximally tolerated dose of an ACE inhibitor or ARB for ≥ 12 weeks prior to initiation, and ≥ 3 months of optimized supportive care (blood pressure management, lifestyle modification, cardiovascular risk modification). Filspari must not be used in combination with ACE inhibitors, ARBs, endothelin receptor antagonists, or aliskiren; these agents should be discontinued prior to initiation.

For IgAN initial therapy: documented biopsy-confirmed diagnosis, proteinuria criteria, AND receipt of maximal or maximally tolerated ACEi or ARB for ≥ 12 weeks.
Optimize supportive care ≥ 3 months prior to starting therapy (blood pressure, lifestyle, CV risk).
Filspari contraindicated with ARBs, ERAs, or aliskiren — these must be discontinued before initiation.
For FSGS: medication will not be used in combination with RAAS antagonists, ERAs, or aliskiren.

Billing Rule

Coding and Plan Document Compliance

Coding and plan document compliance. Claims submitted without covered diagnosis or procedure codes, or not billed using the most appropriate codes as of the submission date, will be denied. Coverage determinations are governed by the applicable benefit plan document, laws/regulations, and supporting policy criteria.

Claims for services not accompanied by covered code(s) under the applicable coverage policy will be denied.
Providers must use the most appropriate diagnosis and procedure codes as of the date of submission and follow the applicable benefit plan terms.

Patient must have received the maximum or maximally tolerated dose of ONE ACE inhibitor or ONE ARB for ≥ 12 weeks prior to starting therapy.

Supportive care requirementPatient must have received ≥ 3 months of optimized supportive care (blood pressure management, lifestyle modification, cardiovascular risk modification).