By Counterforce Health Team in Brensocatib (BRINSUPRI) —

Do You Qualify for Brensocatib (BRINSUPRI) Coverage by UnitedHealthcare in Texas? Decision Tree & Appeal Guide

Answer Box: To get Brensocatib (BRINSUPRI) covered by UnitedHealthcare in Texas, you need: (1) confirmed non-cystic fibrosis bronchiectasis diagnosis, (2) age 12+, (3) documented trial/failure of macrolide antibiotics, and (4) prior authorization through OptumRx. Submit PA via UnitedHealthcare Provider Portal with clinical notes showing ≥2 exacerbations in the past year. If denied, file internal appeal within 180 days, then external review through Texas Department of Insurance if needed. Start by checking your formulary status and gathering documentation of prior treatments.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist & Submission
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternative Options
  6. If Denied: Texas Appeals Playbook
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Costs & Patient Assistance
  10. FAQ

How to Use This Guide

This decision tree helps Texas patients and their providers navigate UnitedHealthcare's coverage requirements for Brensocatib (BRINSUPRI), the first FDA-approved treatment for non-cystic fibrosis bronchiectasis. Work through each section to determine your eligibility and next steps.

Brensocatib requires prior authorization through OptumRx and typically involves step therapy requirements. The medication costs approximately $88,000 per year, making insurance coverage essential for most patients.

Eligibility Triage: Do You Qualify?

Answer these questions to determine your coverage likelihood:

Primary Requirements ✓

  • Age: Are you 12 years or older?
  • Diagnosis: Do you have confirmed non-cystic fibrosis bronchiectasis (not cystic fibrosis)?
  • Exacerbations: Have you had 2 or more bronchiectasis exacerbations in the past year?
  • Prior therapy: Have you tried and failed (or cannot tolerate) macrolide antibiotics like azithromycin?
  • Prescriber: Is your prescription from a pulmonologist or infectious disease specialist?

If You Answered "Yes" to All: Likely Eligible ✅

Proceed to document gathering and prior authorization submission.

If You Answered "No" to 1-2 Items: Possibly Eligible ⚠️

You may need additional documentation or testing before approval.

If You Answered "No" to 3+ Items: Not Yet ❌

Focus on meeting basic criteria first or exploring exception pathways.

If "Likely Eligible": Document Checklist & Submission

Required Documentation

Gather these documents before submitting your prior authorization:

Clinical Records:

  • Bronchiectasis diagnosis confirmation (CT scan, clinical notes)
  • ICD-10 codes: J47.0 (bronchiectasis with acute exacerbation) or J47.9 (bronchiectasis, uncomplicated)
  • Exacerbation log from past 12 months (dates, treatments, outcomes)
  • Current smoking status (must be non-smoker)

Prior Treatment History:

  • Macrolide antibiotic trial records (azithromycin, clarithromycin, erythromycin)
  • Documentation of failure, intolerance, or contraindication
  • Other bronchiectasis treatments tried (airway clearance, bronchodilators)

Provider Documentation:

  • Letter of medical necessity from pulmonologist
  • Current clinical notes within 30 days
  • Monitoring plan for dermatologic and dental side effects

Submission Process

Step 1: Check Formulary Status Log into your UnitedHealthcare member portal and verify Brensocatib's formulary tier and PA requirements for your specific plan.

Step 2: Provider Submission Your provider must submit the PA through:

  • UnitedHealthcare Provider Portal (preferred method as of August 2025)
  • OptumRx e-PA system with PreCheck automation
  • Phone: 888-397-8129 (OptumRx Intake Team)

Step 3: Timeline Expectations

  • Standard PA decision: 30 calendar days
  • Expedited/urgent cases: 72 hours (Medicare) or 24 hours (commercial)
Tip: Use expedited review if waiting could seriously jeopardize your health. Include clear documentation of medical urgency.

If "Possibly Eligible": Tests to Request

If you're missing key eligibility criteria, work with your provider on these steps:

Missing Exacerbation Documentation

  • Request detailed review of past 24 months' medical records
  • Document any hospitalizations, antibiotic courses, or symptom flares
  • Consider prospective tracking if recent exacerbations aren't well-documented

Incomplete Prior Therapy Records

  • Obtain records from previous pulmonologists or primary care providers
  • Document specific macrolide trials: drug name, dose, duration, reason for discontinuation
  • If never tried macrolides, discuss trial with your provider (unless contraindicated)

Specialist Referral Needed

  • Request referral to pulmonologist if currently seeing primary care only
  • Pulmonologist consultation strengthens medical necessity case

Timeline to Re-apply: Allow 2-3 months to gather additional documentation and establish treatment history.

If "Not Yet": Alternative Options

If you don't meet standard criteria, consider these pathways:

Medical Exception Requests

Work with your provider to request coverage exceptions based on:

  • Contraindications to macrolide antibiotics
  • Severe disease with rapid progression
  • Failed standard-of-care treatments beyond macrolides

Alternative Treatments to Document

While building your case for Brensocatib:

  • Off-label macrolides: Azithromycin 250mg three times weekly
  • Rotating antibiotics: Ciprofloxacin, doxycycline cycles
  • Enhanced airway clearance: Vest therapy, hypertonic saline
  • Bronchodilators: Long-acting beta-agonists, anticholinergics

Preparing for Future Application

  • Track all exacerbations prospectively
  • Document response (or lack thereof) to alternative treatments
  • Maintain regular pulmonology follow-up

If Denied: Texas Appeals Playbook

UnitedHealthcare denials can be appealed through multiple levels in Texas:

Internal Appeals Process

Level 1: Standard Internal Appeal

  • Filing deadline: 180 days from denial date
  • Submission: Electronic via UnitedHealthcare Provider Portal (mandatory as of August 2025)
  • Decision timeline: 30 days for standard, 72 hours for expedited
  • Required documents: Denial letter, updated clinical evidence, provider letter of medical necessity

Level 2: Peer-to-Peer Review Request direct physician-to-physician discussion if initial appeal fails.

External Review (Independent Review Organization)

If internal appeals are exhausted:

  • Filing deadline: 4 months from final internal denial
  • Process: Texas Department of Insurance coordinates Independent Review Organization (IRO)
  • Timeline: 20 days standard, 5 days expedited/urgent
  • Cost: Free to patient (UnitedHealthcare pays IRO fees)
  • Outcome: IRO decision is binding on UnitedHealthcare

Contact for IRO: Texas Department of Insurance at 1-800-252-3439

Note: Self-funded employer plans (ERISA) follow federal appeals rules, not Texas IRO process.

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required via OptumRx UHC PA Requirements
Step Therapy Macrolide antibiotic trial required OptumRx Formulary Guidelines
Age Limit 12 years and older FDA Label
Diagnosis Non-cystic fibrosis bronchiectasis FDA Indication
Quantity Limit 30 tablets per 30 days (typical) Plan-specific
Prescriber Pulmonologist preferred Payer policy
Monitoring Plan Dermatologic and dental monitoring FDA Safety Requirements

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit detailed exacerbation log, failed treatments, specialist letter
"Step therapy not met" Document macrolide trial/failure or contraindication with specific details
"New to market/non-formulary" Request formulary exception with clinical justification
"Quantity limit exceeded" Provide dosing rationale and FDA prescribing information
"Missing documentation" Resubmit with complete clinical notes, labs, and prior therapy records
"Wrong prescriber" Transfer prescription to pulmonologist or get co-signature

Costs & Patient Assistance

List Price: Approximately $88,000 annually

Patient Support Options:

  • Insmed inLighten Program: Copay assistance for commercial insurance (verify eligibility at Insmed.com)
  • Foundation grants: Check Patient Access Network Foundation, HealthWell Foundation
  • State programs: Texas has limited specialty drug assistance programs
Important: Patient assistance programs typically don't work with government insurance (Medicare, Medicaid).

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for specialty medications like Brensocatib. Our platform helps patients and providers build stronger cases by identifying the specific denial reasons and crafting point-by-point rebuttals aligned to each payer's own rules, potentially saving months in the appeals process.

FAQ

Q: How long does UnitedHealthcare prior authorization take for Brensocatib in Texas? A: Standard PA decisions take up to 30 days. Expedited reviews (for urgent medical situations) are decided within 72 hours for Medicare or 24 hours for commercial plans.

Q: What if Brensocatib is non-formulary on my UnitedHealthcare plan? A: Request a formulary exception through your provider. Include clinical documentation showing medical necessity and lack of formulary alternatives.

Q: Can I request an expedited appeal if my condition is worsening? A: Yes. If waiting could seriously jeopardize your health, request expedited internal appeal (72 hours) and expedited external review (5 days in Texas).

Q: Does step therapy apply if I tried macrolides outside of Texas? A: Yes. Document all prior treatments regardless of where they occurred. Out-of-state medical records are valid for step therapy requirements.

Q: What happens if UnitedHealthcare is my employer's self-funded plan? A: Self-funded ERISA plans follow federal appeals rules, not Texas external review. You'll use the federal external review process instead of Texas IRO.

Q: How do I know if my case qualifies for expedited review? A: Expedited review applies when waiting for standard processing could seriously harm your health. Your provider must document the medical urgency in the request.

From our advocates: We've seen Brensocatib approvals take 2-3 appeal rounds initially due to its new-to-market status. The key is thorough documentation of exacerbation frequency and failed macrolide trials. Patients who worked with their pulmonologists to create detailed treatment timelines and medical necessity letters had notably higher success rates in our experience. Remember, persistence and complete documentation are crucial for these high-cost, newly approved medications.

When working through UnitedHealthcare's approval process for Brensocatib, having the right documentation and understanding the specific requirements can make the difference between approval and denial. Counterforce Health has helped numerous patients navigate similar specialty drug approvals by creating targeted appeals that address each payer's specific criteria and concerns.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company directly for plan-specific requirements. Coverage criteria and processes may vary by plan and change over time. For personalized assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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