By Counterforce Health Team in Brensocatib (BRINSUPRI) —

Do You Qualify for Brensocatib (BRINSUPRI) Coverage by Humana in Pennsylvania? Complete Decision Tree & Appeal Guide

Answer Box: Get Brensocatib (BRINSUPRI) Covered by Humana in Pennsylvania

Most likely eligible if you have: Non-CF bronchiectasis confirmed by CT scan, ≥2 exacerbations requiring antibiotics in 12 months, and documented trial/failure of macrolide therapy. Fastest path: Have your pulmonologist submit Humana's formulary exception request with medical necessity documentation. Start today: Call Humana member services to confirm formulary status and request prior authorization forms. If denied, Pennsylvania's Independent External Review process has a 50% overturn rate for specialty drug denials.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document & Submit
  4. If "Possibly Eligible": Tests & Timeline
  5. If "Not Yet": Alternatives & Exceptions
  6. If Denied: Pennsylvania Appeal Path
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. FAQ: Brensocatib (BRINSUPRI) & Humana

How to Use This Decision Tree

This guide helps patients and clinicians navigate Humana's coverage requirements for Brensocatib (BRINSUPRI) in Pennsylvania. Start with the eligibility triage below to determine your likely coverage path, then follow the specific section for your situation.

Important notes:

Eligibility Triage: Do You Qualify?

✅ Likely Eligible

You meet ALL of these criteria:

  • Age ≥12 years with non-CF bronchiectasis confirmed by chest CT/HRCT
  • ≥2 pulmonary exacerbations requiring systemic antibiotics in past 12 months (adults) or ≥1 exacerbation (ages 12-17)
  • Documented trial and inadequate response to macrolide therapy (azithromycin/clarithromycin for 3-6 months)
  • Current airway clearance regimen in place
  • Prescribed by or in consultation with a pulmonologist

Next step: Go to "Document & Submit" section below.

⚠️ Possibly Eligible

You meet SOME criteria but need:

  • Recent chest CT to confirm bronchiectasis diagnosis
  • Documentation of exacerbation frequency and antibiotic treatments
  • Formal trial of macrolide therapy
  • Pulmonology consultation

Next step: See "Tests & Timeline" section.

❌ Not Yet Eligible

You have:

  • Cystic fibrosis bronchiectasis
  • <2 exacerbations in past year (adults) or <1 (adolescents)
  • No documented macrolide trial
  • Age <12 years

Next step: Review "Alternatives & Exceptions" section.

If "Likely Eligible": Document & Submit

Required Documentation Checklist

Diagnosis & Severity:

  • Chest CT/HRCT report confirming bronchiectasis
  • ICD-10 codes (J47.x for non-CF bronchiectasis)
  • Baseline spirometry with FEV₁ % predicted
  • Exacerbation log: dates, symptoms, antibiotics used, hospitalizations

Prior Therapy Documentation:

  • Macrolide trial details: drug name, dose, duration, reason for discontinuation
  • Current airway clearance regimen (devices, nebulized therapies, frequency)
  • Other inhaled/oral antibiotics tried with outcomes

Prescriber Requirements:

  • Prescription from pulmonologist or consultation note attached
  • Medical necessity letter addressing formulary alternatives

Submission Process

  1. Call Humana first: Use member services number on your ID card to confirm:
    • Current formulary status of brensocatib
    • Required prior authorization forms
    • Preferred submission method (online portal vs. fax)
  2. Complete forms: Request Humana's formulary exception form and supporting documentation requirements
  3. Submit within timeline: Standard decisions within 72 hours; expedited (24-hour) available for urgent cases
  4. Track status: Use Humana's online portal or call for updates
Tip: Counterforce Health helps patients and clinicians turn insurance denials into targeted appeals by analyzing denial letters and drafting evidence-backed rebuttals aligned to plan policies.

If "Possibly Eligible": Tests & Timeline

Tests to Request

Diagnostic confirmation:

  • High-resolution chest CT if not done within past 2 years
  • Baseline spirometry (FEV₁, FVC, DLCO)
  • Sputum culture for baseline microbiology

Severity documentation:

  • Review medical records for past 12-24 months to document exacerbations
  • Calculate Bronchiectasis Severity Index (BSI) if possible
  • Obtain pulmonology consultation if not already established

Timeline to Reapply

4-8 weeks: Complete diagnostic workup and establish baseline 3-6 months: Trial macrolide therapy (azithromycin 250-500mg 3x/week or daily) Document response: Track exacerbations, symptoms, and tolerability Resubmit: With complete documentation package

What to Track During Preparation

  • Exacerbation frequency and severity
  • Antibiotic courses required
  • Hospitalizations or urgent care visits
  • Quality of life impacts
  • Response to airway clearance and other therapies

If "Not Yet": Alternatives & Exceptions

Alternative Therapies to Discuss

Standard of care options:

  • Long-term macrolide therapy (azithromycin, clarithromycin)
  • Enhanced airway clearance (oscillatory devices, nebulized hypertonic saline)
  • Inhaled antibiotics for chronic Pseudomonas colonization
  • Pulmonary rehabilitation

Exception Request Strategy

Even if you don't meet standard criteria, you may qualify for an exception if:

Clinical circumstances:

  • Severe, frequent exacerbations despite standard therapy
  • Intolerance or contraindications to macrolides
  • Progressive lung function decline
  • Chronic Pseudomonas or NTM colonization

Documentation approach:

  • Detailed medical necessity letter from pulmonologist
  • Literature supporting off-label or compassionate use
  • Quality of life assessments showing significant impairment
  • Risk-benefit analysis for this specific patient

If Denied: Pennsylvania Appeal Path

Pennsylvania offers one of the strongest patient appeal processes in the country through its Independent External Review Program.

Level 1: Humana Internal Appeal

Timeline: 65 days from denial notice Process: Submit written appeal through Humana's member portal Required: Original denial letter, additional medical documentation, prescriber support letter

Level 2: Pennsylvania Independent External Review

Eligibility: After completing Humana's internal appeal process Timeline: 4 months from final denial letter to request external review Success rate: 50% of appeals overturned in program's first year Cost: Free to patients

How to file:

  1. Complete internal appeal and receive final adverse determination
  2. Submit request via Pennsylvania Insurance Department portal
  3. Include all medical records, provider letters, and clinical studies
  4. Independent Review Organization (IRO) decides within 45 days

Expedited review available: 72-hour decision for urgent medical situations

From our advocates: We've seen several successful brensocatib appeals in Pennsylvania where patients provided comprehensive documentation of macrolide failures and detailed exacerbation histories. The key is showing that standard therapies have been optimized but remain inadequate for controlling this patient's specific bronchiectasis progression.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Must get approval before coverage Humana PA search tool Humana Policy
Diagnosis Non-CF bronchiectasis by CT Radiology report, pulmonology note FDA Label
Age ≥12 years Birth date in medical record FDA Label
Exacerbations ≥2/year adults, ≥1/year adolescents Medical records, antibiotic history Payer Policies
Step Therapy Macrolide trial required Prescription history, provider notes Payer Policies
Prescriber Pulmonologist or consultation Provider NPI, consultation note Payer Policies
Appeals Deadline 65 days (internal), 4 months (external) Denial letter date Pennsylvania DOI

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Not on formulary" Submit formulary exception with medical necessity letter showing formulary alternatives ineffective
"Step therapy not met" Document macrolide trial dates, doses, outcomes, and reasons for discontinuation
"Insufficient exacerbations" Provide detailed log of all respiratory infections, antibiotic courses, and healthcare utilization
"Experimental/investigational" Include FDA approval letter (August 2025) and ASPEN trial data showing efficacy
"Not prescribed by specialist" Obtain pulmonology consultation or have current pulmonologist submit request
"Inadequate documentation" Use comprehensive checklist above; include all required elements in single submission

FAQ: Brensocatib (BRINSUPRI) & Humana

How long does Humana prior authorization take in Pennsylvania? Standard decisions within 72 hours of complete submission. Expedited reviews available in 24 hours for urgent medical situations.

What if brensocatib is non-formulary on my Humana plan? Request a formulary exception through Humana's coverage determination process. Your prescriber must document that all formulary alternatives would be less effective or cause adverse effects.

Can I request an expedited appeal in Pennsylvania? Yes. Both Humana and Pennsylvania's external review process offer expedited timelines (24-72 hours) when delays could seriously jeopardize your health.

Does step therapy apply if I failed macrolides outside Pennsylvania? Yes. Document the trial and failure regardless of where it occurred. Include prescription records, provider notes, and specific reasons for discontinuation.

What financial assistance is available for brensocatib? Insmed offers patient support services including benefits verification, prior authorization assistance, and potential co-pay support programs.

How does Pennsylvania's external review compare to other states? Pennsylvania's program is newer (launched January 2024) and has reported a 50% overturn rate, which is higher than many other states' external review processes.

When to Contact Counterforce Health

Consider professional appeals assistance if you face:

  • Complex denial reasons requiring detailed policy analysis
  • Multiple failed internal appeals
  • Tight deadlines for external review submission
  • Need for evidence-backed rebuttal letters

Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan directly. For additional help with Pennsylvania insurance appeals, contact the Pennsylvania Insurance Department Consumer Services at the number listed on their website.

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