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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsFlorida Medicaid Brinsupri Coverage | OpenPayer
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    CurrentAgency for Health Care AdministrationPolicy N/A

    Brinsupri (brensocatib) Coverage Criteria

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    This policy governs prior authorization for Brinsupri (brensocatib) tablets for Medicaid beneficiaries with non-cystic fibrosis bronchiectasis, including initial and continuation therapy criteria, authorization durations, and dosing information.

    Policy Summary
    PayerAgency for Health Care Administration
    PolicyBrinsupri (brensocatib) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit prior authorization documentation demonstrating that all initial or continuation review criteria are met.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6 monthsInitial authorization duration
    1 yearContinuation authorization duration
    >12 yearsMinimum patient age
    10 mg and 25 mgAvailable tablet strengths

    Coverage Criteria Overview

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Initial Therapy Criteria

    Covered for initial therapy when all of the following are met.

    Initial therapy criteria

    • Patient characteristics and diagnosis

      • Patient is older than 12 years.>12 years
      • Patient is not a current smoker.
      • Patient has non-cystic fibrosis bronchiectasis confirmed through high-resolution CT (HRCT) imaging of the chest.
      • Diagnostic testing confirms the patient does not have cystic fibrosis.

    • Disease activity

      • Patient has experienced a pulmonary exacerbation within the previous 12 months, characterized by clinical symptoms such as chronic cough, increased sputum production, and/or recurrent respiratory infections.Within previous 12 months

    • Prior treatment response

      • Documentation shows inadequate treatment response to airway clearance therapy.
      • Documentation shows inadequate treatment response, contraindication, or intolerance to chronic or intermittent antibiotics.
      • Documentation shows inadequate treatment response, contraindication, or intolerance to anti-inflammatory therapies, such as corticosteroids.

        Documentation is required for anti-inflammatory therapy history.

    • Prescriber qualification

      • Medication is prescribed by or in consultation with a pulmonologist or infectious disease specialist.

    Continuation Therapy Criteria

    Covered for continuation therapy when all of the following are met.

    Continuation therapy

    • Prior approval basis

      • Patient met initial review criteria.

    • Clinical benefit or stabilization

      • Documentation demonstrates a reduction in pulmonary exacerbation frequency.
      • Documentation demonstrates improved or stable lung function, such as FEV₁.
      • Documentation demonstrates improved respiratory symptoms or quality of life.

    • Safety and dosing

    Coverage is not available when the patient is a current smoker or has confirmed cystic fibrosis. The diagnosis must instead be non-cystic fibrosis bronchiectasis confirmed by high-resolution CT imaging of the chest, with diagnostic testing confirming the absence of cystic fibrosis.

    Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for Brinsupri (brensocatib). Initial authorization requires documentation of all initial review criteria; continuation authorization requires confirmation that the patient met initial criteria and continues to demonstrate clinical benefit or stabilization without treatment-restricting adverse effects, with appropriate dosing.

    Documentation Required

    Diagnosis and Disease History

    Document the patient’s diagnosis and disease history for initial review, including age, smoking status, HRCT confirmation of non-cystic fibrosis bronchiectasis, exclusion of cystic fibrosis, and a qualifying pulmonary exacerbation within the previous 12 months.

    • Patient must be older than 12 years.
    • Patient must not be a current smoker.
    • Non-cystic fibrosis bronchiectasis (NCFB) must be confirmed by high-resolution CT (HRCT) imaging of the chest.
    • Diagnostic testing must confirm the patient does not have cystic fibrosis.
    • Document a pulmonary exacerbation within the previous 12 months, characterized by symptoms such as chronic cough, increased sputum production, and/or recurrent respiratory infections.
    Documentation Required

    Prior Treatment Response

    Document inadequate response to airway clearance therapy and inadequate response, contraindication, or intolerance to relevant medication therapies before initial authorization.

    • Inadequate response to airway clearance therapy.
    • Inadequate response, contraindication, or intolerance to chronic or intermittent antibiotics.
    • Inadequate response, contraindication, or intolerance to anti-inflammatory therapies, such as corticosteroids; documentation is required.
    Documentation Required

    Specialist Involvement

    Document that Brinsupri is prescribed by, or used in consultation with, a pulmonologist or infectious disease specialist.

    • Prescriber or consulting specialist must be a pulmonologist or infectious disease specialist.
    Documentation Required

    Continuation Documentation

    For continuation authorization, document that the patient met initial review criteria, has demonstrated clinical improvement or disease stabilization, has not experienced treatment-restricting adverse effects, and is receiving an appropriate dose.

    • Clinical improvement or stabilization may include reduced pulmonary exacerbation frequency, improved or stable lung function such as FEV₁, or improved respiratory symptoms or quality of life.
    • Document absence of treatment-restricting adverse effects, including significant dermatologic or periodontal complications.
    • Dosing must be appropriate according to labeling or supported by compendia.
    Denial Risk

    Failure to Meet Initial Clinical Criteria

    Initial authorization may be denied when any required initial clinical criterion is not met or adequately documented.

    • Patient is 12 years of age or younger.
    • Patient is a current smoker.
    • NCFB is not confirmed by chest HRCT, or the diagnosis is not documented.
    • Diagnostic testing does not exclude cystic fibrosis.
    • No pulmonary exacerbation is documented within the previous 12 months.
    • Required documentation of inadequate response to airway clearance therapy is absent.
    • Required documentation regarding antibiotics or anti-inflammatory therapies—including inadequate response, contraindication, or intolerance—is absent.
    • Prescription is not by or in consultation with a pulmonologist or infectious disease specialist.
    Denial Risk

    Failure to Meet Continuation Criteria

    Continuation authorization may be denied when the patient did not meet initial eligibility requirements or when ongoing treatment requirements are not documented.

    • Initial review criteria were not met or cannot be verified.
    • Clinical improvement or disease stabilization is not documented, including improvement or stabilization in exacerbation frequency, lung function, respiratory symptoms, or quality of life.
    • Treatment-restricting adverse effects are present, such as significant dermatologic or periodontal complications.
    • Dosing is not appropriate according to labeling and is not supported by compendia.

    Clinical Definitions

    Non-cystic fibrosis bronchiectasis (NCFB)
    ConditionBronchiectasis that is not associated with cystic fibrosis.
    ConfirmationConfirmed through high-resolution computed tomography (HRCT) imaging of the chest.
    Cystic fibrosis statusDiagnostic testing confirms that the patient does not have cystic fibrosis.
    Pulmonary exacerbation
    DefinitionA worsening episode of pulmonary disease.
    Associated symptomsMay include chronic cough and increased sputum production.
    Additional featureMay include recurrent respiratory infections.
    Review timeframeThe episode must have occurred within the previous 12 months for initial review.

    Initial Therapy Criteria

    Initial Therapy Criteria

    Initial therapy requires all review criteria.

    Initial therapy criteria

    • Patient characteristics and diagnosis

      • Patient is older than 12 years.>12 years
      • Patient is not a current smoker.
      • Patient has non-cystic fibrosis bronchiectasis confirmed through high-resolution CT (HRCT) imaging of the chest.
      • Diagnostic testing confirms the patient does not have cystic fibrosis.

    • Disease activity

      • Patient has experienced a pulmonary exacerbation within the previous 12 months, characterized by clinical symptoms such as chronic cough, increased sputum production, and/or recurrent respiratory infections.Within previous 12 months

    • Prior treatment response

      • Documentation shows inadequate treatment response to airway clearance therapy.
      • Documentation shows inadequate treatment response, contraindication, or intolerance to chronic or intermittent antibiotics.
      • Documentation shows inadequate treatment response, contraindication, or intolerance to anti-inflammatory therapies, such as corticosteroids.

        Documentation is required for anti-inflammatory therapy history.

    • Prescriber qualification

      • Medication is prescribed by or in consultation with a pulmonologist or infectious disease specialist.

    Continuation Therapy Criteria

    Continuation Therapy Criteria

    Continuation of therapy requires all listed criteria.

    Continuation criteria

    • Prior approval basis

      • Patient met initial review criteria.

    • Clinical benefit or stabilization

      • Documentation demonstrates a reduction in pulmonary exacerbation frequency.
      • Documentation demonstrates improved or stable lung function, such as FEV₁.
      • Documentation demonstrates improved respiratory symptoms or quality of life.

    • Safety and dosing

      • Patient has not experienced any treatment-restricting adverse effects, such as significant dermatologic or periodontal complications.
      • Dosing is appropriate as per labeling or is supported by compendia.
    Policy Summary
    PayerAgency for Health Care Administration
    PolicyBrinsupri (brensocatib) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit prior authorization documentation demonstrating that all initial or continuation review criteria are met.
    SourceLink
    On This Page
    Coverage Criteria OverviewAuthorization and Documentation RequirementsClinical DefinitionsInitial Therapy CriteriaContinuation Therapy Criteria
    • Patient has not experienced any treatment-restricting adverse effects, such as significant dermatologic or periodontal complications.
    • Dosing is appropriate as per labeling or is supported by compendia.