By Counterforce Health Team in Brensocatib (BRINSUPRI) —

How to Get Brensocatib (BRINSUPRI) Covered by Blue Cross Blue Shield in Florida: Complete Appeals Guide

Answer Box: Getting Brensocatib (BRINSUPRI) Covered by Blue Cross Blue Shield in Florida

Fastest Path: 1) Check if BRINSUPRI is on your Florida Blue formulary via their Drug Search tool. 2) If not listed or requires PA, submit prior authorization with documented macrolide failure/contraindication and ≥2 exacerbations/year. 3) Use electronic submission (CoverMyMeds) for faster processing. First step today: Call the pharmacy number on your Blue Cross Blue Shield ID card to verify coverage status and PA requirements for your specific plan.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
PA Required Prior authorization needed before coverage Florida Blue formulary/medication guide Drug Search Tool
Step Therapy Must try macrolides first PA criteria (not yet published for BRINSUPRI) PA Information
Formulary Status Likely non-formulary initially 2025 Medication Guides CareChoices Guide
Appeals Deadline 180 days from denial Plan documents Appeal Rights
External Review 4 months from final denial Florida DFS Consumer Services

Step-by-Step: Fastest Path to Approval

1. Verify Your Plan's Coverage Status

Who: Patient or clinic staff
Action: Check your specific Florida Blue product's formulary for BRINSUPRI
How: Use the Florida Blue Drug Search or call the pharmacy number on your ID card
Timeline: Same day

2. Gather Required Clinical Documentation

Who: Your pulmonologist
Documents needed:

  • HRCT confirming non-CF bronchiectasis
  • Exacerbation log (past 12 months with dates, antibiotics, hospitalizations)
  • Macrolide trial history (drug, dose, duration, reason for discontinuation)
  • Current PFTs and sputum cultures Timeline: 1-2 weeks to compile

3. Submit Prior Authorization Request

Who: Prescribing physician
Method: Electronic PA via CoverMyMeds (fastest) or Prime Therapeutics fax
Include: Detailed medical necessity letter addressing step therapy and frequent exacerbations
Timeline: 2-3 business days for electronic; 10-15 days for fax
Source: Florida Blue PA Process

4. Request Peer-to-Peer Review if Denied

Who: Prescribing physician
Action: Call the P2P number listed in denial letter
Preparation: Have full chart, imaging, and culture results available
Timeline: Usually scheduled within 1-2 business days
Source: Quick Reference Guide

5. File Internal Appeal if P2P Unsuccessful

Who: Patient with physician support
Deadline: 180 days from denial notice
Method: Written appeal with updated medical necessity letter
Decision timeline: 30 days (standard), 72 hours (expedited)
Source: Appeal Process

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Step therapy not met" Document macrolide trial failure or contraindication Pharmacy records, progress notes showing side effects/lack of efficacy
"Not medically necessary" Emphasize ≥2 exacerbations/year despite standard care Detailed exacerbation log, hospital records, antibiotic courses
"Non-formulary drug" Request formulary exception Letter explaining why formulary alternatives are inappropriate
"Insufficient documentation" Provide complete clinical picture HRCT reports, PFTs, microbiology, specialist consultation notes
From Our Advocates: We've seen multiple Florida Blue denials overturned when physicians clearly documented why azithromycin was stopped (e.g., QT prolongation, severe GI intolerance) and provided a month-by-month exacerbation timeline. The key is addressing each specific denial reason with objective clinical data.

Appeals Playbook for Florida Blue

Internal Appeal Process

  1. Level 1 Internal Appeal
    • Deadline: 180 days from denial
    • Method: Written request with supporting documentation
    • Decision timeline: 30 days (standard), 72 hours (expedited)
    • Submit to: Address/portal specified in denial letter
  2. Expedited Appeal (When Applicable)
    • Criteria: Delay would seriously jeopardize health
    • Timeline: 72 hours or less
    • Required: Physician attestation of urgency

External Review (Florida-Specific)

  • Eligibility: After exhausting internal appeals
  • Deadline: 4 months from final internal denial
  • Process: Request through Florida Department of Financial Services
  • Cost: Free to consumer
  • Decision: Binding on Florida Blue

Medical Necessity Letter Checklist

Essential Elements for Brensocatib Coverage

Patient Information:

  • Member ID and plan details
  • Confirmed non-CF bronchiectasis diagnosis (ICD-10: J47.x)
  • Age ≥12 years (FDA indication requirement)

Clinical Severity:

  • ≥2 documented exacerbations in past 12 months
  • Objective measures (FEV1, HRCT findings, hospitalizations)
  • Impact on quality of life and functional status

Prior Treatment History:

  • Macrolide therapy details (drug, dose, duration, outcome)
  • Reason for macrolide discontinuation or contraindication
  • Airway clearance techniques tried
  • Other bronchiectasis medications attempted

Supporting Evidence:

  • Reference to FDA approval for bronchiectasis
  • Cite relevant guidelines (ATS/ERS bronchiectasis guidelines)
  • Expected clinical benefits (reduced exacerbations)
Clinician Corner: When documenting macrolide failure, be specific. Instead of "patient didn't tolerate azithromycin," write "azithromycin 250mg daily discontinued after 3 months due to QTc prolongation from 420ms to 485ms, confirmed on repeat ECG." This level of detail significantly strengthens your case.

Costs & Patient Assistance

Manufacturer Support

  • Insmed Patient Services: Check www.brinsupri.com for patient assistance programs (verify availability)
  • Copay assistance: May be available for commercially insured patients

Alternative Funding Sources

  • HealthWell Foundation: Provides grants for pulmonary conditions
  • Patient Access Network Foundation: Covers specialty medications
  • Florida-specific programs: Contact Florida Department of Health for state assistance programs

Cost Considerations

  • List price: Approximately $88,000/year
  • Insurance negotiated rates: Vary significantly by plan
  • Specialty pharmacy requirement: Likely required for dispensing

At Counterforce Health, we help patients navigate complex specialty drug approvals by analyzing denial letters and crafting targeted appeals that address each payer's specific criteria. Our platform has successfully helped numerous bronchiectasis patients get coverage for high-cost therapies after initial denials.

When to Request External Review

Consider external review through Florida DFS when:

  • Internal appeals have been exhausted
  • Denial is based on medical necessity (not administrative issues)
  • You have strong clinical evidence supporting the need for Brensocatib
  • Your physician believes the denial was inappropriate

Process:

  1. File within 4 months of final internal denial
  2. Submit clinical records and physician support letter
  3. Independent medical expert reviews case
  4. Decision is binding on Florida Blue

FAQ: Brensocatib Coverage in Florida

How long does Florida Blue prior authorization take?

Electronic submissions via CoverMyMeds typically receive decisions within 2-3 business days. Faxed requests may take 10-15 days. Expedited reviews for urgent cases are decided within 72 hours.

What if Brensocatib isn't on my formulary?

You can request a formulary exception by demonstrating medical necessity and lack of appropriate alternatives. This requires detailed documentation of why covered drugs are inappropriate for your specific case.

Can I get an expedited appeal?

Yes, if your physician certifies that delay would seriously jeopardize your health or ability to regain function. Expedited appeals are decided within 72 hours.

Does step therapy apply if I tried macrolides outside Florida?

Yes, prior therapy from other states counts. Ensure you have complete records including drug names, doses, duration, and reasons for discontinuation.

What counts as macrolide failure?

Typical criteria include: inadequate response after 3-6 months of appropriate dosing, intolerable side effects, or contraindications (QT prolongation, drug interactions, NTM infection risk).

How do I prove I have frequent exacerbations?

Maintain a detailed log including dates, symptoms, antibiotics prescribed, ER visits, and hospitalizations. Medical records from your pulmonologist documenting each episode strengthen your case.

Can I appeal both denial and high cost-sharing?

Yes, Florida residents can appeal both coverage denials and unaffordable cost-sharing determinations through separate processes.

What if my employer plan is self-funded?

Self-funded ERISA plans follow federal rather than Florida state appeal rules. Check your Summary Plan Description for specific procedures and deadlines.

Timeline: From Request to Resolution

Week 1-2: Gather documentation, submit PA
Week 3: Receive initial decision
Week 4-5: P2P review if denied
Week 6-9: Internal appeal if needed
Month 4-8: External review if internal appeals fail

For complex cases requiring multiple appeal levels, Counterforce Health's platform can help streamline the process by automatically generating targeted appeal letters that address your specific payer's criteria and denial reasons.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan documents for the most current coverage policies and procedures. Appeal rights and timelines may vary by specific plan type and employer group.

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