ModifiedCignaPolicy N/A

Pulmonary - Brinsupri Prior Authorization Policy

This Cigna prior authorization policy defines medical necessity criteria, prescriber requirements, approval durations, and non-covered uses for Brinsupri (brensocatib tablets) for treatment of non-cystic fibrosis bronchiectasis in patients aged 12 years and older.

Policy Summary

PayerCigna

PolicyPulmonary - Brinsupri Prior Authorization Policy

Policy CodePolicy N/A

Change TypeRevised criteria and documentation requirements

Effective Date

Next Review Date

Key ActionObtain prior authorization and document chest CT–diagnosed bronchiectasis, qualifying antibiotic-treated exacerbations, prescriber specialty (pulmonologist or infectious disease), smoking status, and clinical response for continuation.

POLICY UPDATE CHANGES

Diagnostic requirement for initial therapy changed to 'history of bronchiectasis as diagnosed by chest computed tomography' and removal of prior five-year time limit.

Diagnostic requirement removed for patients currently receiving Brinsupri.

Exacerbation requirements updated to require that qualifying exacerbations resulted in prescription of an antibiotic agent for both pediatric and adult thresholds.

Requirement that respiratory symptoms are not driven primarily by COPD or asthma updated from a broader list of comorbid respiratory conditions.

Specialist prescriber requirement expanded to include infectious disease physicians in addition to pulmonologists.

Examples of beneficial clinical response for continuation therapy were updated to include reduced cough, reduced sputum production, or less shortness of breath.

1Approval duration (years)