CommercialPrior AuthMedium impact
Pharmacy coverage changes
Harvard Pilgrim Health Care·Nephrology, Internal Medicine, Pharmacy·Pharmacy
Effective date
Nov 1, 2025
We identified it
Jun 26, 2026
Summary
Point32Health updated prior authorization coverage criteria for two specialty kidney disease medications (Filspari and Tarpeyo) effective November 1, 2025. Both drugs now require documented proteinuria ≥1 g/day and a mandatory 3-month trial of first-line therapies (ACEi, ARB, SGLT2i, and supportive care) before approval. Filspari has an additional contraindication restriction prohibiting concurrent use with ACEi, ARB, endothelin receptor antagonist, or aliskiren.
Action Required
By October 15, 2025: Prior Authorization team must update Point32Health prior auth guidelines in billing system to enforce new coverage criteria for Filspari (sparsentan) and Tarpeyo (budesonide). Providers submitting requests must now submit: (1) documentation of proteinuria ≥1 g/day, (2) evidence of completed 3-month trial of ACEi/ARB/SGLT2i, and (3) for Filspari only, confirmation that patient is NOT currently on ACEi, ARB, endothelin receptor antagonist, or aliskiren. Update rejection templates and prior auth request forms to clearly communicate these new requirements. Inform nephrology and primary care providers in writing of the 3-month trial mandate and contraindication restrictions. Claims for these medications submitted without meeting criteria will be denied. Begin tracking for Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, and RITogether plans immediately upon effective date.