Brensocatib (BRINSUPRI) for non-cystic fibrosis bronchiectasis
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This policy governs prior authorization, approval duration, and renewal criteria for BRINSUPRI (brensocatib) for treatment of non-cystic fibrosis bronchiectasis for MedImpact members and prescribers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Brensocatib (BRINSUPRI)
Initial Approval
Covered when ALL of the following are met:
Renewal Criteria
Renewal covered when ONE of the following demonstrates a positive response to therapy:
Provider attestation required
This policy applies specifically to patients with non-cystic fibrosis bronchiectasis. Cases of bronchiectasis that are related to cystic fibrosis are excluded by the diagnosis requirement and are not covered under this policy.
Provider Requirements and Authorization
Prior authorization required with attestations and specialist involvement
Prior authorization is required. The request must include provider attestation of a non-cystic fibrosis bronchiectasis diagnosis confirmed by chest CT, that the drug is prescribed by or in consultation with a pulmonologist or other specialist, age- and exacerbation-specific attestations (≥18 y with ≥2 exacerbations OR 12–17 y with ≥1 exacerbation), and confirmation of antibiotic-treated exacerbations in the past 12 months. Initial approval duration is 6 months; quantity limit 1 tablet per day; minimum age ≥ 12 years.
- Attest diagnosis: non-cystic fibrosis bronchiectasis confirmed by chest CT
- Attest prescriber: prescribed by or in consultation with a pulmonologist or specialist
- Attest exacerbation history: ≥2 (≥18 y) OR ≥1 (12–17 y)
- Attest antibiotic-treated exacerbations in past 12 months
- Attest smoking status and counseling if current smoker
- Approval duration: 6 months initial; Quantity limit: 1 tablet/day; Age limit: ≥12 years
No step therapy required
No step therapy or trials of other agents are specified in this policy; the document does not require prior medication trials before authorization.
Required documentation and attestations
Requests must include documentation and provider attestations: chest CT confirmation of non-CF bronchiectasis; that the medication is prescribed by or in consultation with a pulmonologist or other specialist; specific attestations of exacerbation count and that exacerbations required antibiotic treatment in the past 12 months; and documentation of smoking status with counseling if the patient is a smoker.
- Chest CT confirming non-cystic fibrosis bronchiectasis
- Evidence prescriber is a pulmonologist or documentation of specialist consultation
- Attestation of age-specific exacerbation count (≥2 for ≥18 y; ≥1 for ages 12–17)
- Attestation that exacerbations required antibiotic treatment in past 12 months
- Attestation of smoking status and counseling if current smoker
Triggers for denial: missing attestations or unmet exacerbation/specialist criteria
Denial may be issued if required attestations or documentation are missing or criteria are not met, including absence of chest CT confirmation, lack of specialist prescribing/consultation, failure to meet the age-specific exacerbation thresholds, or no record that exacerbations required antibiotics in the past 12 months.
- Missing chest CT confirmation of non-CF bronchiectasis
- Prescriber not a pulmonologist and no documented specialist consultation
- Exacerbation criteria not met (≥2 for ≥18 y; ≥1 for ages 12–17)
- No documentation that exacerbations required antibiotic treatment in past 12 months
Key Definitions
Background
Non-cystic fibrosis bronchiectasis is a chronic pulmonary condition characterized by bronchial dilation and recurrent exacerbations. Brensocatib (BRINSUPRI) is intended to reduce exacerbation frequency in this population. For initial approval the policy requires provider attestation of a diagnosis of non-cystic fibrosis bronchiectasis confirmed by chest CT, prescribing by or consultation with a pulmonologist or relevant specialist, age- and exacerbation-specific thresholds (either ≥ 18 years with ≥ 2 exacerbations or ages 12–17 years with ≥ 1 exacerbation), documentation that the exacerbations required antibiotic treatment in the past 12 months, and an attestation regarding smoking status with counseling if the patient is a current smoker.
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