By Counterforce Health Team in Brensocatib (BRINSUPRI) —

Getting Brensocatib (BRINSUPRI) Covered by Humana in Georgia: Complete Prior Authorization and Appeals Guide

Answer Box: To get Brensocatib (BRINSUPRI) covered by Humana in Georgia, you'll need prior authorization with documented failure of macrolide antibiotics and airway clearance therapies. Submit Humana's PA form with ICD-10 code J47.1 (bronchiectasis with exacerbation), NDC 71558-002, and clinical notes showing medical necessity. If denied, you have 65 days to file an internal appeal, then 60 days for external review through Georgia's Department of Insurance. Start by gathering your CT scan results and prior treatment records today.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Brensocatib (BRINSUPRI) is an oral medication that typically falls under Medicare Part D pharmacy benefits rather than Part B medical benefits. This distinction is crucial for proper billing and coverage approval.

Pharmacy Benefit Path (Most Common):

  • Covered under Humana's Medicare Part D formulary
  • Requires prior authorization through pharmacy benefit management
  • Uses NDC numbers for identification
  • Subject to quantity limits (typically 30 tablets per 30 days)

Medical Benefit Path (Rare):

  • Only applies if Humana specifically classifies it as a medical benefit
  • Would require HCPCS J-code J3490 (miscellaneous drug)
  • Must include NDC on the medical claim
  • Requires stronger medical necessity documentation
Note: Always verify with Humana's current formulary which benefit covers BRINSUPRI for your specific plan.

ICD-10 Mapping for Non-Cystic Fibrosis Bronchiectasis

Proper ICD-10 coding is essential for Brensocatib approval. Use these specific codes based on the patient's current clinical status:

Primary ICD-10 Codes:

  • J47.1: Bronchiectasis with (acute) exacerbation - Most common for PA requests
  • J47.0: Bronchiectasis with acute lower respiratory infection
  • J47.9: Bronchiectasis, uncomplicated (stable disease)

Documentation Requirements: Your medical records must include:

  • High-resolution CT scan confirming bronchiectasis
  • Chronic productive cough for ≥6 months
  • Frequency of exacerbations (≥2 per year requiring antibiotics)
  • Clear statement that bronchiectasis is NOT due to cystic fibrosis
Clinician Corner: Document symptom chronology, exacerbation frequency, and prior treatment failures in detail. Humana reviewers look for specific language like "failed azithromycin therapy due to [intolerance/ineffectiveness]" and "inadequate response to airway clearance techniques."

Product Coding: NDC, HCPCS, and Billing Units

NDC Numbers:

  • Primary NDC: 71558-002 (BRINSUPRI 25 mg tablets)
  • Always confirm the exact NDC with your specialty pharmacy

HCPCS Coding:

  • Pharmacy benefit: Use NDC only
  • Medical benefit (if applicable): J3490 + NDC 71558-002

Billing Units and Dosing:

  • Standard dose: 25 mg once daily (30 tablets per month)
  • Billing unit = 1 tablet
  • Monthly quantity: 30 units for 30-day supply

Unit Conversion Example:

  • Prescription: BRINSUPRI 25 mg, take 1 tablet daily
  • 30-day supply = 30 tablets = 30 billing units
  • Enter "30" as quantity on PA forms

Clean Prior Authorization Request

A complete PA request includes all required elements to avoid delays:

Essential Components:

  1. Patient Information: Full name, DOB, Humana member ID
  2. Prescriber Details: NPI, DEA, contact information
  3. Drug Information:
    • BRINSUPRI (brensocatib) 25 mg tablets
    • NDC: 71558-002
    • Quantity: 30 tablets per 30 days
  4. Diagnosis: ICD-10 J47.1 (or appropriate J47.x code)
  5. Clinical Justification: See medical necessity criteria below
  6. Supporting Documents: CT scan, lab results, prior therapy records

Medical Necessity Checklist:

  • CT scan confirming non-cystic fibrosis bronchiectasis
  • Documented chronic productive cough ≥6 months
  • ≥2 exacerbations per year requiring antibiotics
  • Failed or inadequate response to macrolide antibiotics
  • Trial of airway clearance therapies documented
  • No contraindications to BRINSUPRI

Common Coding Pitfalls to Avoid

Frequent Mistakes:

Error Correct Approach Impact
Using cystic fibrosis codes (E84.x) Use only J47.x codes for non-CF bronchiectasis Automatic denial
Missing CT scan documentation Include radiology report confirming bronchiectasis Denial for insufficient evidence
Vague prior therapy notes Document specific macrolide tried, duration, outcome Step therapy denial
Incorrect quantity calculations 25 mg daily = 30 tablets/month Quantity limit rejection
Using wrong NDC Verify 71558-002 with pharmacy Claim processing delays

Pre-Submission Verification:

  • Cross-check NDC with Humana's formulary
  • Confirm current PA form version
  • Verify specialty pharmacy is in-network

Humana Coverage Requirements

Step Therapy Requirements: Humana typically requires documented failure of:

  1. Macrolide antibiotic (azithromycin, clarithromycin, or erythromycin)
  2. Airway clearance therapy (chest physiotherapy, oscillatory devices, or positive expiratory pressure)

Quantity Limits:

  • Standard: 30 tablets per 30 days
  • Annual prior authorization renewal required
  • Coverage limited to FDA-approved indication

Prior Authorization Process:

  • Submit via Humana provider portal or fax
  • Standard review: 7 calendar days for Part D
  • Expedited review: 72 hours with physician urgency certification
From our advocates: We've seen Humana approvals come faster when the PA includes a clear timeline of prior treatments with specific dates and outcomes. One case involved a patient whose initial denial was overturned within 3 days of submitting detailed azithromycin failure documentation with exact dates and side effects.

Appeals Process in Georgia

If your initial PA is denied, Georgia residents have specific rights and timelines:

Internal Appeal (Redetermination):

  • Deadline: 65 days from denial date
  • Timeline: 7 calendar days for standard review, 72 hours for expedited
  • How to file: Humana member portal or call 1-800-451-4651
  • Required: Redetermination form and supporting clinical documentation

External Review (Georgia DOI):

  • When: After internal appeal is denied
  • Deadline: 60 days from Humana's final denial
  • Timeline: 30 business days (72 hours if expedited)
  • Cost: Free for consumers
  • Contact: Georgia Department of Insurance at 1-800-656-2298

Expedited Appeals: Request expedited review if:

  • Delay could seriously harm your health
  • You need the medication urgently
  • Your doctor provides written urgency certification

Required Documents for Appeals:

  • Copy of original denial letter
  • Updated clinical notes supporting medical necessity
  • Physician letter explaining urgency (for expedited appeals)
  • Any new relevant test results or documentation

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with each payer's specific requirements, helping patients and clinicians navigate complex prior authorization processes more effectively.

FAQ

How long does Humana prior authorization take for BRINSUPRI in Georgia? Standard PA decisions take 7 calendar days for Part D drugs. Expedited reviews (with physician urgency certification) are completed within 72 hours.

What if BRINSUPRI is non-formulary on my Humana plan? You can request a formulary exception by demonstrating medical necessity and failure of preferred alternatives. The process uses the same PA forms and timelines.

Can I get an expedited appeal if I'm already taking BRINSUPRI? Yes, if your doctor certifies that stopping the medication would seriously jeopardize your health. Submit expedited appeal forms with physician urgency documentation.

Does step therapy apply if I failed macrolides outside of Georgia? Yes, documented failure of required therapies from any location counts toward step therapy requirements, provided you have medical records proving the trial and outcome.

What's the difference between internal and external appeals? Internal appeals are reviewed by Humana staff within 65 days of denial. External appeals are reviewed by independent physicians through Georgia's Department of Insurance within 60 days of internal appeal denial.

How much does BRINSUPRI cost with Humana coverage? Costs vary by plan tier and coverage phase. Contact Humana member services for your specific copay or coinsurance amounts. Patient assistance programs may be available through Insmed's patient support.

When to Contact Georgia Regulators

If you're experiencing unreasonable delays or denials, contact:

  • Georgia Department of Insurance Consumer Services: 1-800-656-2298
  • Online complaint form: Available on the Georgia DOI website
  • Georgians for a Healthy Future: Nonprofit providing consumer assistance with insurance appeals

For complex cases involving multiple denials or procedural issues, consider working with Counterforce Health, which helps patients and providers create comprehensive appeals that address payer-specific requirements and maximize approval chances.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Coverage decisions are made by insurance plans based on individual circumstances and current policies. Always consult with your healthcare provider and verify current requirements with Humana before making treatment decisions. For personalized assistance with prior authorizations and appeals, consider consulting with healthcare coverage specialists.

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