Non-cystic fibrosis bronchiectasis agents (brensocatib)
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Prior authorization criteria for formulary non-cystic fibrosis bronchiectasis agents (specifically brensocatib/Brinsupri) for AllCare Advantage members; governs coverage decisions for prescribers and pharmacy benefit staff.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met.
If all met -> approve up to 6 months; if not met -> deny
Continuation / Renewal
Covered when ALL of the following are met.
If met -> approve up to 12 months; if not met -> deny
This policy applies to the FDA‑approved population for brensocatib (Brinsupri): treatment of non‑cystic fibrosis bronchiectasis (NCFB) in patients 12 years of age and older. The diagnosis must be confirmed by noncontrast chest computed tomography (CT). Requests should be for maintenance/preventive therapy prescribed by a lung specialist, and documentation should address airway clearance therapy or provide a clinical reason for its absence.
A request is considered not medically necessary when the member has not been established on standard preventive therapies for exacerbation reduction — specifically trials of antibiotics, inhaled bronchodilators, and glucocorticoids — with documented good adherence (≤75% adherence does not meet the policy requirement). Additionally, requests lacking documentation of two or more exacerbations in the prior year despite appropriate antibiotic therapy (e.g., macrolide) or an antipseudomonal inhaled antibiotic will be denied.
Coding and Adherence Metrics
| N/A | Document does not list specific CPT/HCPCS/ICD-10/NDC codes; refers generically to formulary agent(s) and quantity limits in formulary print document. |
Provider Actions and Documentation Requirements
Prior authorization required; approval durations and FDA labeling
Prior authorization is required for formulary non‑cystic fibrosis bronchiectasis agents. Initial approvals are for up to 6 months; renewals may be approved for up to 12 months. Member must meet FDA‑approved labeling (age ≥12 years) and the policy’s listed clinical criteria.
Step‑therapy: trial of standard preventive therapies required
Member must have tried/failed first‑line standard-of-care prevention therapies (antibiotics, inhaled bronchodilators, and glucocorticoids) and be established on these therapies with good compliance (>75% adherence) before a formulary agent will be approved.
Required documentation to support prior authorization
Provide documentation confirming diagnosis and prior treatments: non‑cystic fibrosis bronchiectasis diagnosis confirmed by noncontrast chest CT; documentation of airway clearance therapy (or reason it was not used); evidence of trials of standard preventive therapies and adherence (>75%); and documentation of two or more exacerbations in the prior year despite appropriate antibiotic therapy (e.g., macrolide) or an antipseudomonal inhaled antibiotic.
Denial triggers: lack of prior standard therapy or documented exacerbations
Requests will be denied if the member is not established on standard preventive therapies for exacerbation prevention (antibiotics, inhaled bronchodilators, glucocorticoids) with good adherence (>75%), or if there is no documentation of two or more exacerbations in the prior year despite trial of appropriate antibiotic or antipseudomonal inhaled antibiotic.
Definitions
Background
Non‑cystic fibrosis bronchiectasis (NCFB) is a chronic pulmonary condition characterized by irreversible bronchial dilation and recurrent respiratory exacerbations; diagnosis is radiographic, typically by noncontrast chest CT. Clinical management focuses on preventing exacerbations and preserving lung function using airway clearance techniques plus pharmacologic measures. Standard preventive strategies include chronic or targeted antibiotic therapy, inhaled bronchodilators, and inhaled or systemic glucocorticoids where indicated; brensocatib (Brinsupri) is an additional option for patients meeting FDA labeling and the policy’s criteria when standard measures and documented adherence have failed to prevent recurrent exacerbations.
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