Brinsupri (brensocatib) prior authorization
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Prior authorization requirements for prescribing Brinsupri (brensocatib) for pulmonary indications, including initial and reauthorization criteria; applies to providers submitting requests to CareOregon.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met for initial authorization (approval length 6 months):
Diagnosis
- A: COPD or asthma pathway: Diagnosis for COPD or asthma AND submission of medical records (e.g., chart notes) confirming persistent symptoms or exacerbations while adherent to one of the following combination inhalers: for asthma: LABA/ICS (Advair, Symbicort, generic AirDuo, AirDuo); for COPD: LABA/LAMA (Anoro Ellipta, Stiolto Respimat)
- B: NCFB pathway: Diagnosis of non-cystic fibrosis bronchiectasis confirmed by chest CT scan
Exclusionary conditions prevent approval
Each exacerbation must have required antibiotic therapy and meet the symptom definition
Reauthorization
Covered when ALL of the following are met for reauthorization (approval length 12 months):
Approval will be denied if the member has any of the following exclusionary conditions: cystic fibrosis, immunodeficiency, or an active bacterial pulmonary infection/pulmonary tuberculosis (TB). These conditions are listed as absolute exclusions and must not be present at the time of prior authorization review.
Coding and Clinical Thresholds
Provider Actions and Documentation
Prior authorization required for initial and reauthorization
Prior authorization is required for both initial therapy (approval length 6 months) and reauthorization (approval length 12 months) of Brinsupri (brensocatib); requests must meet the policy's clinical criteria and be prescribed by or in collaboration with a pulmonologist.
Required prior inhaler therapy (LABA/ICS or LABA/LAMA)
For the COPD or asthma pathway, the member must have persistent symptoms or exacerbations despite adherence to specified combination inhalers: for asthma, a LABA/ICS (e.g., Advair, Symbicort, AirDuo); for COPD, a LABA/LAMA (e.g., Anoro Ellipta, Stiolto Respimat).
Provide medical record confirmation of prior inhaler therapy
Submit medical records (for example, chart notes) confirming the member had persistent symptoms or exacerbations while adherent to one of the specified combination inhalers.
- Documentation must show persistence of symptoms or occurrence of exacerbations despite adherence to the listed LABA/ICS or LABA/LAMA products.
Chest CT required to confirm NCFB diagnosis
For the non‑cystic fibrosis bronchiectasis (NCFB) pathway, include imaging documentation confirming the diagnosis by chest CT scan.
Document prior exacerbations and antibiotic treatments
Provide evidence of at least two pulmonary exacerbations in the past 12 months that required antibiotic therapy; include details of antibiotics used and the symptoms during each exacerbation.
- Specify antibiotics used (examples listed in policy: ciprofloxacin, doxycycline, amoxicillin, amoxicillin/clavulanate).
- Document symptoms for each exacerbation (e.g., increased cough, increased sputum volume/change, increased sputum purulence, increased breathlessness, decreased exercise tolerance, fatigue/malaise, hemoptysis).
Exclusionary conditions will prevent approval
Denial risk if the member has cystic fibrosis, an immunodeficiency, or an active bacterial pulmonary infection/tuberculosis; these conditions exclude approval.
Diagnosis must meet COPD, asthma, or CT‑confirmed NCFB criteria
Denial risk if the submitted diagnosis does not meet one of the policy pathways: COPD or asthma with required prior inhaler documentation, or non‑cystic fibrosis bronchiectasis confirmed by chest CT.
Minimum age requirement: 12 years
Denial risk if the member is younger than 12 years of age; members must be 12 years of age or older.
Background
Brensocatib (Brinsupri) is indicated under this prior authorization policy for pulmonary conditions including COPD, asthma, and non‑cystic fibrosis bronchiectasis (NCFB) when patients meet the specified clinical criteria. For COPD or asthma, documentation must show persistent symptoms or exacerbations despite adherence to specified combination inhalers (asthma: LABA/ICS; COPD: LABA/LAMA). For NCFB, the diagnosis must be confirmed by chest CT. The policy also requires that patients be ≥ 12 years of age and have experienced ≥ 2 pulmonary exacerbations in the prior 12 months that required antibiotic therapy.
Definitions
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