CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Bronchitol (mannitol inhalation powder) coverage

Defines medical necessity and authorization criteria for Bronchitol (mannitol inhalation powder) as add-on maintenance therapy for adults with cystic fibrosis under Neighborhood Health Plan of Rhode Island (Medicaid scope).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBronchitol (mannitol inhalation powder) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date/1/2021

Next Review DateN/A

Key ActionObtain prior authorization with documentation of a passed Bronchitol Tolerance Test, baseline FEV1, specialist involvement, and prior therapy failures or contraindications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum age for coverage

12 moapproval period

20 / 560capsules/day / 28 days

2021-2025policy review history

Coverage Criteria for Bronchitol (mannitol inhalation powder)

Initial and reauthorization criteria

Covered when ALL of the following are met:

Eligibility and indication: Member is at least 18 years of age AND Bronchitol is prescribed as add-on maintenance to improve pulmonary function for cystic fibrosis (FDA‑approved indication).

Tolerance test: Member has passed the Bronchitol Tolerance Test with documentation and did not experience bronchospasm, decrease in oxygen saturation, or other specified adverse events during the test.

Specialist involvement: Medication prescribed by or in consultation with a pulmonologist or physician who specializes in the treatment of cystic fibrosis.

Prior therapies:

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBronchitol (mannitol inhalation powder) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date/1/2021

Next Review DateN/A

Key ActionObtain prior authorization with documentation of a passed Bronchitol Tolerance Test, baseline FEV1, specialist involvement, and prior therapy failures or contraindications.

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.

Provider Requirements and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approval may be granted for up to 12 months when all listed criteria are met.

Authorization duration: up to 12 months
Applies to Bronchitol (for cystic fibrosis, adults ≥18 years)

Step Therapy

Step Therapy Required

Step therapy requirement: member must have tried and failed, or have a documented contraindication to, both hypertonic saline and Pulmozyme (dornase alfa) prior to approval.

Step therapy applies before initial authorization

Documentation Required

Required Documentation

Documentation required with the prior authorization request: include Bronchitol Tolerance Test results (showing the member passed and did not experience bronchospasm, significant oxygen desaturation, or other adverse events) and baseline lung function measurements (e.g., FEV1).

Bronchitol Tolerance Test results must be submitted
Baseline FEV1 and/or other lung function test documentation required

Denial Risk

Indication Restriction

Indication restriction: Bronchitol is approved only as add-on maintenance therapy to improve pulmonary function in adults (≥18 years) with cystic fibrosis who have passed the Bronchitol Tolerance Test and meet all other criteria. All other indications beyond the FDA‑approved adult cystic fibrosis indication are considered experimental/investigational and not medically necessary.

Prescribed by or in consultation with a pulmonologist or cystic fibrosis specialist
Member must be ≥18 years of age
Member must have passed Bronchitol Tolerance Test
Member must have tried/failed or have contraindication to hypertonic saline and Pulmozyme

Definitions

Bronchitol Tolerance Test — definition and required documentation elements

DefinitionBronchitol Tolerance Test: a required test to confirm patient tolerance to Bronchitol prior to use; documentation must show the patient passed the test and did not experience bronchospasm, a decrease in oxygen saturation, or other specified adverse events.

Required documentationDocumentation of passing the Bronchitol Tolerance Test must be included with the prior authorization request.

Adverse events to document absence ofNo bronchospasm and no decrease in oxygen saturation occurred during the tolerance test.

Timing/use requirementBronchitol should be used only in adults (≥18 years) who have passed the Bronchitol Tolerance Test.

PurposeConfirms patient can tolerate inhaled mannitol (Bronchitol) before initiating add-on maintenance therapy for cystic fibrosis.

OpenPayer

Bronchitol (mannitol inhalation powder) coverage

Coverage Criteria for Bronchitol (mannitol inhalation powder)

Provider Requirements and Authorization Rules

Background on Bronchitol

Definitions