How to Get Brensocatib (BRINSUPRI) Covered by Aetna CVS Health in New York: Complete Appeals Guide with Forms and Timelines
Answer Box: Getting Brensocatib Covered by Aetna CVS Health in New York
Brensocatib (BRINSUPRI) requires prior authorization from Aetna CVS Health with strict step therapy requirements: documented trial and failure of a macrolide antibiotic and airway clearance therapy. In New York, you have strong appeal rights through the state's external review system if initially denied. First step today: Have your pulmonologist gather documentation of macrolide failure and airway clearance trials, then submit the CVS Caremark prior authorization form via their provider portal. If denied, you have 180 days to appeal internally, then 4 months to request external review through New York's Department of Financial Services.
Table of Contents
- Coverage at a Glance
- Step-by-Step: Fastest Path to Approval
- Read the Denial: Understanding Aetna's Decision
- Fixable Causes: Common Issues You Can Resolve
- First-Level Appeal: Building Your Case
- Peer-to-Peer Review: Direct Doctor Discussion
- External Review: New York's Independent Appeal Process
- Scripts and Templates
- Costs and Patient Assistance
- FAQ
Coverage at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Required before coverage | CVS Caremark provider portal | CVS Caremark PA Process |
| Step Therapy | Must try macrolide + airway clearance first | Aetna policy documents | Aetna Specialty Pharmacy |
| Prescriber Requirements | Pulmonologist or ID specialist preferred | PA form specifications | CVS PA Forms |
| Appeals Deadline | 180 days from denial | Member handbook | Aetna Appeals Overview |
| External Review (NY) | 4 months after final denial | NY DFS website | NY External Appeals |
Step-by-Step: Fastest Path to Approval
1. Gather Required Documentation (Patient + Clinic)
Who: Your pulmonologist's office
Documents needed: CT scan showing bronchiectasis, records of ≥2 exacerbations in past 12 months, macrolide trial documentation, airway clearance therapy records
Timeline: 1-2 weeks to collect
Source: CVS Caremark PA Requirements
2. Complete Prior Authorization Form (Clinic)
Who: Prescribing physician
Document: CVS Caremark Global Prior Authorization Form
Submit via: CVS provider portal or fax
Timeline: Same day submission possible
Source: CVS PA Form
3. Submit Supporting Clinical Letter (Clinic)
Who: Pulmonologist
Content: Medical necessity statement addressing step therapy failures
Timeline: Include with PA form
Expected decision: 7-15 business days (72 hours if expedited)
4. Monitor Decision (Patient + Clinic)
Who: Both patient and clinic should track
Method: CVS provider portal, phone follow-up
Timeline: Standard review 7-15 days, expedited 72 hours
5. If Denied: Request Peer-to-Peer (Clinic)
Who: Prescribing physician
How: Call number on denial letter within 14 days
Timeline: Usually scheduled within 3-5 business days
Source: Aetna P2P Process
6. File Internal Appeal if Still Denied (Patient or Clinic)
Who: Either patient or provider can initiate
Form: Aetna Provider Complaint and Appeal Request Form
Timeline: Must file within 180 days of denial
Source: Aetna Appeal Form
7. Request External Review in New York (Patient)
Who: Patient (after exhausting internal appeals)
Agency: NY Department of Financial Services
Timeline: 4 months from final internal denial
Fee: $25 (waived for Medicaid/hardship)
Source: NY DFS External Appeals
Clinician Corner: Medical Necessity Letter Checklist
When submitting your prior authorization or appeal, your medical necessity letter should include:
Essential Clinical Elements:
- Diagnosis confirmation: Non-cystic fibrosis bronchiectasis confirmed by chest CT/HRCT with ICD-10 code J47.x
- Exacerbation history: Document at least 2 exacerbations in prior 12 months requiring antibiotic treatment, with specific dates and treatments
- Step therapy documentation: Detailed records of macrolide trial (drug, dose, duration, reason for discontinuation) and airway clearance therapy attempts
- Contraindications/failures: Specific clinical reasons why formulary alternatives are inappropriate
- Treatment goals: Clear statement of expected clinical outcomes with Brensocatib
Supporting Evidence:
- Reference FDA approval and ASPEN trial data showing efficacy in reducing exacerbations
- Cite current bronchiectasis treatment guidelines supporting use after macrolide failure
- Include relevant specialist consultation notes if available
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| "Step therapy not completed" | Document macrolide and airway clearance failures | Detailed pharmacy records, treatment logs with dates and outcomes |
| "Not medically necessary" | Provide clinical evidence of exacerbation frequency | Hospital/ER records, antibiotic prescriptions, pulmonologist notes |
| "Experimental/investigational" | Reference FDA approval status | FDA approval notice, prescribing information |
| "Non-formulary drug" | Request formulary exception | CVS formulary exception process with supporting clinical rationale |
Appeals Playbook for Aetna CVS Health in New York
Internal Appeals Process
Level 1 - Standard Appeal
- Timeline: 180 days from denial to file
- Decision time: 30 days (72 hours if expedited)
- How to file: Aetna appeal form via mail, fax, or online portal
- Required: Copy of denial letter, medical records, clinical justification
Level 2 - Expedited Appeal (if urgent)
- When to use: Delay would seriously jeopardize health
- Timeline: 72 hours for decision
- Requirements: Physician attestation of urgency
New York External Review
After exhausting Aetna's internal appeals, New York residents can request an independent external review:
Eligibility: Final adverse determination from Aetna on medical necessity, experimental treatment, or out-of-network coverage Timeline: Must request within 4 months of final internal denial Process: Submit application via NY DFS Portal Cost: $25 fee (waived for Medicaid or financial hardship) Decision time: 30 days standard, 72 hours expedited, 24 hours for non-formulary drugs Binding: Yes - if overturned, Aetna must cover treatment and refund your fee
From our advocates: We've seen many Brensocatib denials overturned on external review in New York when providers include detailed documentation of macrolide failures and cite the drug's FDA approval for the specific indication. The key is presenting a clear timeline showing standard treatments were tried and failed before requesting this newer therapy.
Scripts and Templates
Patient Phone Script for Aetna CVS Health
"Hello, I'm calling about a prior authorization denial for Brensocatib, also called BRINSUPRI, for my bronchiectasis. My member ID is [ID number]. I'd like to understand the specific reasons for denial and request information about filing an appeal. Can you also tell me if I can request a peer-to-peer review between my doctor and your medical director?"
Clinic Script for Peer-to-Peer Request
"I'm requesting a peer-to-peer review for [patient name] regarding the denial of Brensocatib for non-cystic fibrosis bronchiectasis. The patient has documented failure of macrolide therapy and meets FDA-approved indications. I have supporting clinical evidence to discuss with your medical director. Please schedule this at your earliest convenience."
Costs and Patient Assistance
List Price: Approximately $88,000 per year Patient Options:
- Insmed Patient Support: Contact manufacturer for copay assistance and prior authorization support
- Foundation Grants: Check eligibility with organizations like Patient Access Network Foundation
- State Programs: New York residents may qualify for additional assistance through state pharmaceutical programs
Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific denial reason and crafting evidence-backed rebuttals aligned to your plan's own policies. Their platform can help identify the exact clinical documentation needed to meet Aetna's criteria and draft appeals that address each denial point systematically.
When to Escalate: New York State Resources
If your appeals are unsuccessful, you can file a complaint with New York regulators:
New York Department of Financial Services
- Consumer Helpline: 800-342-3736
- Online complaints: DFS complaint portal
- What to include: All denial letters, appeal responses, clinical documentation
Community Health Advocates
- Free assistance: 888-614-5400
- Services: Help with appeals, understanding rights, filing external reviews
FAQ
Q: How long does Aetna CVS Health prior authorization take for Brensocatib in New York? A: Standard reviews take 7-15 business days. Expedited reviews (when urgency is documented) are completed within 72 hours.
Q: What if Brensocatib isn't on my Aetna formulary? A: You can request a formulary exception using the CVS Caremark exception process. Your doctor must document that formulary alternatives would be less effective or cause adverse effects.
Q: Can I get expedited appeals in New York? A: Yes, both Aetna and New York's external review process offer expedited reviews when delay would jeopardize your health. Your physician must provide written attestation of urgency.
Q: Does step therapy apply if I tried macrolides in another state? A: Yes, documented step therapy from any location should count. Ensure your new provider has complete records of previous treatments and their outcomes.
Q: What happens if New York's external review overturns Aetna's denial? A: The decision is binding on Aetna. They must cover the treatment and refund your $25 appeal fee. Coverage typically begins within days of the favorable decision.
Q: Can my doctor request a peer-to-peer review after I'm already denied? A: Yes, peer-to-peer reviews can be requested after denials, typically within 14 days. This allows your physician to discuss the case directly with Aetna's medical director.
Q: Are there alternatives if all appeals fail? A: Consider clinical trials, manufacturer patient assistance programs, or working with Counterforce Health to identify any missed appeal opportunities or alternative coverage pathways.
Q: How do I prove macrolide failure for step therapy requirements? A: Provide pharmacy records showing the specific macrolide prescribed, dosage, duration of trial, and documented clinical notes explaining why treatment was discontinued (ineffectiveness, side effects, or contraindications).
Sources & Further Reading
- Aetna Appeals Process Overview
- CVS Caremark Prior Authorization Forms
- New York External Appeals Process
- FDA BRINSUPRI Approval Information
- Medicare Part D Exception Process
- Aetna Provider Appeal Form
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance company directly for the most current coverage policies. Appeal processes and timelines may vary based on your specific plan and state regulations.
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