CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Filspari (sparsentan) for primary IgA nephropathy — Coverage Criteria

Defines coverage and authorization criteria for Filspari (sparsentan) to slow kidney function decline in adults with primary immunoglobulin A nephropathy (IgAN) for Neighborhood Health Plan of Rhode Island Medicaid members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFilspari (sparsentan) for primary IgA nephropathy — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date10/1/2023

Next Review DateN/A

Key ActionObtain prior authorization with documentation of nephrologist involvement, biopsy-confirmed primary IgAN, proteinuria >=1 g/day or UPCR >=0.8 g/g, and eGFR ≥30 and <90 mL/min/1.73 m2.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsInitial and continuation authorization duration

>=1 g/day or >=0.8 g/gProteinuria threshold

30–89eGFR window

1 tab/dayQuantity limit

Adults with IgANIndication population

Coverage Criteria for Filspari (sparsentan)

inv-01: Initial authorization criteria

Covered when ALL of the following are met for adults with primary IgAN:

Prescriber: Medication prescribed by or in consultation with a nephrologist.

Authorization of 6 months may be granted when criteria are met.

Diagnosis: Biopsy-confirmed primary immunoglobulin A nephropathy (IgAN).

Proteinuria: Laboratory documentation of proteinuria >= 1 g/day on 24-hour urine OR UPCR >= 0.8 g/g.>=1 g/day or >=0.8 g/g

Based on a 24-hour urine collection or equivalent laboratory report/chart note.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFilspari (sparsentan) for primary IgA nephropathy — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date10/1/2023

Next Review DateN/A

Key ActionObtain prior authorization with documentation of nephrologist involvement, biopsy-confirmed primary IgAN, proteinuria >=1 g/day or UPCR >=0.8 g/g, and eGFR ≥30 and <90 mL/min/1.73 m2.

SourceLink

On This Page

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inv-02: Continuation (Reauthorization) criteria

Continuation authorization — all of the following must be met:

Authorization duration: Authorization of 6 months may be granted for continued treatment when criteria are met.6 months

Benefit evidence: Documentation (laboratory report and/or chart notes) showing clinical benefit: decreased proteinuria from baseline on 24-hour urine collection OR decrease in UPCR from baseline.

Safety/eGFR stability: No evidence of unacceptable toxicity or disease progression while on current regimen; documented eGFR remains within referenced range (>=30 and <90 mL/min/1.73 m2).eGFR >=30 and <90

Authorization, Documentation, and Prescriber Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Initial authorizations may be granted for up to 6 months when all required criteria are met. Continuation/re-authorization may be granted for additional 6-month periods when documentation demonstrates ongoing benefit and absence of unacceptable toxicity or disease progression.

Prior authorization required for initiation and continuation
Initial authorization: up to 6 months
Continuation/reauthorization: up to 6 months with required documentation

Denial Risk

Indication Limitation

Use of this medication is limited to slowing kidney function decline in adults with biopsy‑confirmed primary immunoglobulin A nephropathy (IgAN) who meet the policy clinical criteria. All other indications are considered experimental/investigational and are not medically necessary.

Indication limitation: Primary IgAN only (biopsy-confirmed)
Other uses: experimental/investigational — not medically necessary

Documentation Required

Documentation, Prior Therapy, and Denial Risk

Approval is contingent on submission of required clinical documentation and prior therapy: nephrologist prescribing or consult note; kidney biopsy confirming primary IgAN; laboratory reports/chart notes showing proteinuria ≥1 g/day or UPCR ≥0.8 g/g (24‑hour collection) and eGFR ≥30 and <90 mL/min/1.73 m2; documentation of a stable dose of a maximally tolerated RAS inhibitor (ACEI or ARB) for at least 3 months prior to initiation OR documentation of intolerance/contraindication to RAS inhibitors. Absence of these documentation elements, or concomitant use with prohibited agents (e.g., ERA, aliskiren, Tarpeyo, Fabhalta), may result in denial.

Required documentation: nephrologist note/consult and kidney biopsy confirming primary IgAN
Required labs: proteinuria ≥1 g/day or UPCR ≥0.8 g/g (24‑hour) and eGFR ≥30 and <90 mL/min/1.73 m2
Prior therapy: stable maximally tolerated ACEI or ARB for ≥3 months prior to initiation, or documented intolerance/contraindication to RAS inhibitors
Denial risk: missing biopsy confirmation, insufficient proteinuria/eGFR documentation, lack of prior/stable RAS inhibitor therapy, or concurrent use with prohibited agents

OpenPayer

Filspari (sparsentan) for primary IgA nephropathy — Coverage Criteria

Coverage Criteria for Filspari (sparsentan)

Key Clinical Thresholds and Coding

Authorization, Documentation, and Prescriber Requirements

Background

Definitions and Thresholds