CurrentMass General Brigham Health PlanPolicy N/A

Brinsupri (brensocatib) for non-cystic fibrosis bronchiectasis

Pharmacy prior authorization policy for Brinsupri (brensocatib) for treatment of non-cystic fibrosis bronchiectasis (NCFB) in members aged 12 years and older; applies to Commercial/Exchange lines and specialty pharmacy dispensing.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBrinsupri (brensocatib) for non-cystic fibrosis bronchiectasis

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization through the pharmacy benefit and submit CT confirmation of NCFB, documentation ruling out cystic fibrosis, age, pulmonologist involvement, clinical history, and pulmonary exacerbation history as applicable; specialty pharmacy dispensing is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12Initial and reauthorization approval duration

≥12Minimum eligible age

1Quantity limit (tablets/day)

Medical Necessity Criteria for Brinsupri (brensocatib)

Initial Authorization — Medical Necessity Criteria

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Diagnosis of non-cystic fibrosis bronchiectasis (NCFB) confirmed by computed tomographic (CT) scan

Diagnostic testing confirms member does not have cystic fibrosis

Member is 12 years of age or older

Requested medication is prescribed by or in consultation with a pulmonologist

Documentation confirming clinical history consistent with NCFB (e.g., chronic cough or sputum production or recurrent respiratory tract infections)

Exacerbation history requirement (ONE of):

Adolescents 12–17 years
- Member is 12 - 17 years of age
- Documentation of at least one pulmonary exacerbation requiring systemic antibiotics in the previous 12 months
Adults ≥ 18 years
- Member is 18 years of age or older
- Documentation of at least two pulmonary exacerbations requiring systemic antibiotics in the previous 12 months

Coexisting airway disease requirement (ONE of):

Member does not have co-existing chronic obstructive pulmonary disease (COPD) or asthma
If co-existing COPD
- Documentation that the member is receiving one of the following therapies: triple therapy (ICS+LAMA+LABA) or LAMA+LABA if ICS is contraindicated
If co-existing asthma
- Documentation the member is currently being treated with one of the following medications or had a contraindication or intolerance: (1) ICS AND an additional asthma controller (e.g., LTRA, LABA, or LAMA) OR (2) Combination ICS/LABA product

Continuation (Reauthorization) Criteria

Requests for reauthorization will be approved when the following criteria are met:

ALL of the following

Documentation demonstrating the member has had a positive clinical response to therapy
Examples include stabilization or reduction in number of pulmonary exacerbations

Coverage for Members New to Plan

Authorization may be granted for members new to the plan within the past 90 days who are currently receiving treatment with the requested medication, excluding samples or manufacturer patient assistance

ALL of the following

Member new to the plan within the past 90 days AND is currently receiving brensocatib (not obtained as samples or via manufacturer patient assistance programs)

Coding Notes and Quantity Limits

No codes specifiedmixed

No codes listed

Policy-level billing notesmixed

Pharmacy Benefit	Brinsupri (brensocatib) dispensed via pharmacy benefit; specialty pharmacy dispensing required
Prior Authorization	Prior authorization required through the pharmacy benefit for Brinsupri (brensocatib)
Quantity Limit	Brinsupri tablet: 1 tablet per day

Key Thresholds

Minimum age12 years

Initial/renewal approval duration12 months

Quantity limit1 tablet per day

Exacerbation requirement, ages 12–17≥ 1 pulmonary exacerbation treated with systemic antibiotics in prior 12 months

Exacerbation requirement, age ≥18≥ 2 pulmonary exacerbations treated with systemic antibiotics in prior 12 months

Administrative and Prescribing Requirements

Prior Authorization

Prior authorization required

Prior authorization is required through the pharmacy benefit for Brinsupri (brensocatib). The product is designated specialty and must be dispensed at a contracted specialty pharmacy.

Documentation Required

Document diagnostic confirmation and treatment history

Provide documentation confirming NCFB by CT scan, evidence that cystic fibrosis has been ruled out, the member's age, that the medication is prescribed by or in consultation with a pulmonologist, clinical history consistent with NCFB, and pulmonary exacerbation history including number of exacerbations and that they were treated with systemic antibiotics as applicable.

Documentation Required

Document coexisting airway disease treatment

If the member has coexisting COPD or asthma, include documentation of current inhaled controller therapies or evidence of contraindication/intolerance.

For COPD: documentation of receiving triple therapy (ICS + LAMA + LABA) or LAMA + LABA if ICS is contraindicated.
For asthma: documentation of either (1) an ICS plus an additional asthma controller (e.g., LTRA, LABA, or LAMA) or (2) a combination ICS/LABA product, or documentation of contraindication/intolerance.

Prior Authorization

New-to-plan continuity

For members new to the plan within the past 90 days who are currently receiving brensocatib, submit evidence of ongoing treatment to obtain authorization; therapies obtained as samples or via manufacturer's patient assistance programs do not qualify.

Clinical and Policy Context

Brensocatib (Brinsupri) is a dipeptidyl peptidase-1 (DPP-1) inhibitor indicated to reduce pulmonary exacerbations in patients with non-cystic fibrosis bronchiectasis (NCFB) aged 12 years and older. Authorization for Brinsupri through the pharmacy benefit is aligned to confirmation of an NCFB diagnosis by computed tomographic (CT) scan, documentation that cystic fibrosis has been ruled out, and a clinical history consistent with bronchiectasis (for example, chronic cough, sputum production, or recurrent respiratory infections). The policy requires documentation of pulmonary exacerbation history per age-based thresholds and that the medication be prescribed by or in consultation with a pulmonologist.

This is a pharmacy prior authorization policy that applies to Commercial/Exchange lines of business and requires specialty pharmacy dispensing. Prior authorization is required through the pharmacy benefit for Brinsupri, and requests from members new to the plan may be considered if the member has been receiving the medication within the prior 90 days (excluding samples or manufacturer patient-assistance supplied product).

Policy Dates & Revision Notes

Document-level metadata: the policy header contains effective and review dates that should be used in the document header. The policy effective date is 2026-03-01 and the most recent review date is 2026-01-14 as noted in the review history.

The brief contains no dated changes entries to populate a changes timeline; the brief.changes array is empty, so do not create additional timeline items. Use the document header and the changes list (which is empty) for official metadata. Initial approvals and reauthorizations are listed as 12 months in the policy limitations and should be reflected in the header where appropriate.