CurrentAvMedPolicy N/A

Brinsupri (brensocatib) prior authorization for bronchiectasis

Form and clinical criteria governing prior authorization and step-edit requests for Brinsupri (brensocatib) for AvMed members; applies to prescribers requesting coverage through AvMed's pharmacy prior authorization process.

Policy Summary

PayerAvMed

PolicyBrinsupri (brensocatib) prior authorization for bronchiectasis

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with prescriber signature and required documentation (CT confirmation, exacerbation history, prior therapy verification) via fax to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsApproval period

≥ 12 yrsMinimum age

30 tabsQuantity limit

10 or 25 mgDosage

Non-smokerSmoking status

Coverage Criteria

Initial Authorization

Covered when ALL of the following are met

Age and prescriber: Member is >= 12 years of age AND Brinsupri is prescribed by or in consultation with a pulmonologist.age >= 12

chunk 3

Diagnostic confirmation: Bronchiectasis diagnosed by chest computed tomography in the last five years (documentation required).CT within 5 years

chunk 3

Exacerbation history requirement: For members >= 12 and < 18 years: at least one pulmonary exacerbation in the prior 12 months requiring an antibiotic prescription, urgent care/ER visit, or hospitalization; For members >= 18 years: at least two pulmonary exacerbations in the prior 12 months requiring an antibiotic prescription, urgent care/ER visit, or hospitalization.

Policy Summary

PayerAvMed

PolicyBrinsupri (brensocatib) prior authorization for bronchiectasis

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with prescriber signature and required documentation (CT confirmation, exacerbation history, prior therapy verification) via fax to 1-305-671-0200.

SourceLink

On This Page

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.

1 (12-17) or 2 (>=18) exacerbations in 12 months

Exclude cystic fibrosis: Member does NOT have cystic fibrosis.no cystic fibrosis

chunk 3

Not primarily driven by other conditions: Provider attests bronchiectasis is NOT driven primarily by other comorbid respiratory conditions (e.g., asthma, COPD, alpha-1 antitrypsin deficiency, known or suspected immunodeficiency).attestation

chunk 3

Non-smoker: Member is a current non-smoker.non-smoker status

chunk 3

Prior therapies tried/failed: Member has tried and failed appropriate antibiotics and other optimal supportive treatments for bronchiectasis (e.g., chronic/intermittent macrolide therapy, other systemic antibiotics, inhaled antibiotics, expectorants/mucolytics, airway clearance techniques, and other adjunct therapies where clinically appropriate); verification via chart notes or pharmacy paid claims required.documented prior therapies

chunks 3,4

Dose limit: Prescribed dose does NOT exceed the maximum daily dose of one tablet per day for 10 mg or 25 mg strengths.<=1 tablet/day

chunk 4

Reauthorization

Reauthorization covered when ALL of the following are met

Continuation of initial criteria: Member continues to meet all initial authorization criteria.same as initial

chunk 4

Toxicity absence: Provider attests to an absence of unacceptable toxicity from therapy (e.g., hyperkeratosis, periodontitis/gingivitis, severe infections).no unacceptable toxicity

chunk 5

Clinical improvement: Provider must submit clinical notes documenting clinical improvement (e.g., reduction in number of exacerbations or preservation of lung function) while on Brinsupri.documented clinical improvement

chunk 5

Coverage is excluded when the member has cystic fibrosis. The policy requires that the member does NOT have cystic fibrosis as a condition of approval for Brinsupri (brensocatib).

Therapy is not medically necessary and does not meet criteria if the member fails to satisfy the diagnostic confirmation or exacerbation-frequency requirements, is a current smoker, or when the prescribed dose exceeds the single-tablet daily limit. Specifically, the policy requires a chest CT diagnosis of bronchiectasis within the prior five years and age‑dependent pulmonary exacerbation history (for ages 12–17: ≥1 exacerbation in the prior 12 months; for ages ≥18: ≥2 exacerbations in the prior 12 months). The provider must also attest that bronchiectasis is not driven primarily by other comorbid respiratory conditions and that the member is a current non-smoker.

Initial Therapy Criteria

Initial therapy criteria

Initial authorization criteria

Age and prescriber: Member is >=12 years and prescribed by or in consultation with a pulmonologist.age >=12

chunk 3

Diagnostic confirmation: Bronchiectasis confirmed by chest CT in the last 5 years (documentation required).CT within 5 years

chunk 3

Exacerbation history: Pediatric (>=12 and <18): at least one pulmonary exacerbation in the prior 12 months requiring an antibiotic prescription, urgent care/ER visit, or hospitalization; Adult (>=18): at least two pulmonary exacerbations in the prior 12 months requiring an antibiotic prescription, urgent care/ER visit, or hospitalization.1 or 2 exacerbations depending on age

chunk 3

Prior therapy trial: Documentation of trials and failures of appropriate antibiotics and supportive therapies as detailed on the form (e.g., chronic/intermittent macrolide therapy, other systemic antibiotics, inhaled antibiotics, expectorants/mucolytics, airway clearance techniques, and other adjunct therapies).'documented prior therapies

chunks 3,4

Dose limit: Prescribed dose does not exceed one tablet per day (10 mg or 25 mg strengths).<=1 tablet/day

chunk 4

Continuation / Reauthorization Criteria

Continuation / Reauthorization

Reauthorization requirements

Meet initial criteria: Member continues to meet all initial authorization criteria.same as initial

chunk 4

No unacceptable toxicity: Provider attests absence of unacceptable toxicity from therapy (examples include hyperkeratosis, periodontitis/gingivitis, severe infections).no unacceptable toxicity

chunk 5

Documented clinical benefit: Clinical notes documenting improvement (e.g., fewer exacerbations or preserved lung function) must be submitted with the reauthorization request.documented benefit

chunk 5

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Submission

Prior authorization is required for Brinsupri (brensocatib). The prescribing physician must sign and clearly print their name (preprinted stamps not valid). Fax the completed request and supporting documentation to 1-305-671-0200. Incomplete, incorrect, or illegible information (including missing phone/fax numbers) may delay processing or result in denial.

Prior authorization required for Brinsupri (brensocatib)
Prescriber signature and printed name required
Fax completed form and documentation to 1-305-671-0200
Ensure phone and fax numbers are included to avoid delays

Documentation Required

Required Documentation & Form Completion

Complete member and prescriber fields and all drug information. Authorization may be delayed if fields are incomplete. The prescriber must include member identifiers (Member name, AvMed #, DOB), prescriber name, NPI, prescriber signature and date, office contact name, phone and fax numbers. For the drug, include name/form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight and date obtained, recommended dosage, and requested quantity.

Member identifiers: Member name, AvMed #, Date of Birth
Prescriber: name, NPI, signature (hand-signed), date
Office contact: name, phone number, fax number
Drug details: name/form/strength, dosing schedule, length of therapy, diagnosis, ICD code, weight and date, recommended dosage, quantity limit (30 tablets/30 days)

Step Therapy

Step Therapy / Prior Treatment Requirements

Document prior therapies and supportive treatments trialed and failed where clinically appropriate. Submit chart notes and/or pharmacy paid claims to verify previous use of listed therapies; samples do not satisfy step-edit/ prior treatment requirements.

Antibiotics: chronic or intermittent macrolide therapy (e.g., azithromycin); other systemic antibiotics (e.g., β-lactams or tetracyclines)
Inhaled antibiotics (e.g., tobramycin, aztreonam)
Expectorants and mucolytics (e.g., hypertonic saline, dornase alfa, mannitol, acetylcysteine)
Airway clearance techniques (e.g., chest physiotherapy, mechanical percussion vests, breathing techniques)
Other adjunct therapies as clinically indicated (e.g., inhaled bronchodilators, anti-inflammatory medications, GERD management)

Documentation Required

Clinical & Step Criteria Documentation

For initial authorization, include documentation that all clinical criteria are met: age (≥12 years), pulmonologist involvement, CT-confirmed bronchiectasis within 5 years, exacerbation history thresholds (1 for ages 12–17; 2 for ≥18), absence of cystic fibrosis, bronchiectasis not primarily driven by other comorbid respiratory conditions, current non-smoker status, and that prescribed dose does not exceed one tablet daily for indicated strengths. For reauthorization, submit clinical notes documenting continued benefit and absence of unacceptable toxicity (e.g., hyperkeratosis, periodontitis/gingivitis, severe infections).

Initial authorization length: 12 months; Reauthorization: 12 months
Clinical criteria required and must be supported by chart notes/labs/diagnostics
Pulmonary exacerbation definition and required history documentation
Provider attestation regarding comorbid conditions and smoking status
Documentation of prior therapies (see Step Therapy block) — pharmacy paid claims accepted
Submit clinical notes showing improvement for reauthorization and document absence of significant toxicity

Coding & Age Limits

Requested/diagnosis code entrymixed

N/A	No specific CPT/HCPCS/ICD-10 codes listed on form; field present for ICD code entry

Age

Minimum member age>= 12 years

Prescriber requirementPrescribed by or in consultation with a pulmonologist

Approval periodInitial authorization: 12 months

Step Therapy Requirements

Prior therapy / supportive treatment (check all that apply)	Notes / examples
Antibiotics
Chronic or intermittent macrolide therapy (e.g., azithromycin); other systemic antibiotics (e.g., β‑lactams or tetracyclines)
Inhaled antibiotics
Inhaled antibiotics (e.g., tobramycin, aztreonam)
Expectorants and mucolytics
Examples: hypertonic saline, dornase alfa, mannitol, acetylcysteine
Airway clearance techniques
Examples: chest physiotherapy, mechanical percussion vests, breathing techniques
Other adjunct therapies
Examples: inhaled bronchodilators, anti‑inflammatory medications, management of GERD
Documentation verification
Prior therapies must be verified by chart notes and/or pharmacy paid claims; use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Quantity Limits

Brinsupri (brensocatib) — Quantity & Strength

Quantity limit30 tablets per 30 days (both strengths)

Recommended dosages10 mg or 25 mg once daily

Maximum daily doseOne tablet per day (10 mg or 25 mg)

Definitions

Pulmonary exacerbation — definition

Symptom criteriaWorsening of three or more of: increased cough; increased sputum volume or change in sputum consistency; increased sputum purulence; increased breathlessness; decreased exercise tolerance; fatigue and/or malaise; hemoptysis

Required timeframeSymptoms worsened over 48 hours

Exacerbation verificationEach exacerbation must have required an antibiotic prescription, urgent care/ER visit, or hospitalization (for exacerbation-history counts)

Background

Brinsupri (brensocatib) is indicated under this policy for members with bronchiectasis confirmed by chest computed tomography. The form requires submission of documentation showing bronchiectasis was diagnosed by chest CT within the last five years. In addition, the policy defines a pulmonary exacerbation as worsening of three or more major symptoms over 48 hours (for example, increased cough, increased sputum volume or change in sputum consistency, increased sputum purulence, increased breathlessness, decreased exercise tolerance, fatigue or malaise, and hemoptysis) and uses exacerbation history to determine eligibility.