By Counterforce Health Team in Brensocatib (BRINSUPRI) —

How to Get Brensocatib (BRINSUPRI) Covered by Blue Cross Blue Shield in Ohio: Cost Reduction, Appeals & Patient Assistance

Answer Box: Getting Brensocatib (BRINSUPRI) Covered in Ohio

Blue Cross Blue Shield Ohio will likely require prior authorization for Brensocatib (BRINSUPRI) and place it on a specialty tier (Tier 4-5) given its ~$88,000 annual list price. First steps: Verify your plan's formulary status, gather documentation of 2+ bronchiectasis exacerbations per year, and apply for Insmed's inLighten copay assistance if you have commercial insurance. If denied, Ohio residents can pursue external review through the Ohio Department of Insurance within 180 days.

Table of Contents

  1. What Drives Brensocatib Costs
  2. Investigating Your Benefits
  3. Assistance Options
  4. Formulary Tier Exceptions
  5. Specialty Pharmacy Requirements
  6. Appeals on Cost Grounds
  7. Annual Renewal Planning
  8. Conversation Scripts
  9. FAQ

What Drives Brensocatib Costs

Brensocatib (BRINSUPRI) became the first FDA-approved treatment for non-cystic fibrosis bronchiectasis in August 2025, with a reported list price of approximately $88,000 per year. As a first-in-class DPP1 inhibitor, it represents a significant advance for patients who previously relied on off-label treatments like macrolides.

Benefit Design Factors

Your out-of-pocket costs depend on several key factors:

  • Formulary tier placement: Specialty drugs typically land on Tier 4 or 5, requiring higher coinsurance (often 25-40% of drug cost)
  • Annual deductible: High-deductible plans may require you to pay the full cost until your deductible is met
  • Out-of-pocket maximum: Once reached, your plan covers 100% of additional costs
  • Specialty pharmacy requirements: Blue Cross Blue Shield Ohio mandates specialty pharmacy dispensing for coverage
Note: Even with a high list price, your actual cost may be significantly lower due to manufacturer assistance programs and insurance negotiated rates.

Investigating Your Benefits

Before starting treatment, gather this essential information about your Blue Cross Blue Shield Ohio coverage:

Key Questions for Member Services

Call the number on your insurance card and ask:

  1. "Is Brensocatib (BRINSUPRI) covered on my formulary?"
  2. "What tier is it placed on, and what's my coinsurance?"
  3. "Is prior authorization required?"
  4. "Which specialty pharmacies are in-network?"
  5. "What's my annual out-of-pocket maximum?"

Information to Record

Document these details for future reference:

  • Prior authorization form number and submission process
  • Specialty pharmacy network requirements
  • Step therapy requirements (if any)
  • Quantity limits per fill
  • Your specific coinsurance percentage

Verify current formulary information on Anthem Ohio's website

Assistance Options

Manufacturer Copay Assistance

Insmed's inLighten Patient Support Program offers copay assistance for commercially insured patients. Key details:

  • Eligibility: Commercial insurance only (no Medicare, Medicaid, or TRICARE)
  • Typical savings: Industry standard copay cards often reduce costs to $0-$50 per prescription
  • Annual limits: Most programs cap assistance at several thousand dollars per year
  • Enrollment: Requires prescriber completion of enrollment form and patient consent

Contact inLighten Patient Support for current program details and maximum benefit amounts.

Important: Government insurance beneficiaries cannot use manufacturer copay cards due to federal anti-kickback regulations.

Foundation Grants

As Brensocatib is newly approved, dedicated foundation grants are still developing. Monitor these organizations for future bronchiectasis-specific programs:

  • PAN Foundation: Disease-specific grants for specialty medications
  • HealthWell Foundation: Copay assistance for chronic conditions
  • Patient Advocate Foundation: Case management and financial assistance

Counterforce Health Support

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies specific denial reasons—whether prior authorization criteria, step therapy requirements, or "not medically necessary" determinations—and drafts point-by-point responses aligned with your plan's own rules. For patients facing Brensocatib denials, this targeted approach can significantly improve appeal success rates.

Formulary Tier Exceptions

If Brensocatib is placed on a high-cost tier or excluded from your formulary, you can request a formulary exception to move it to a lower tier with reduced cost-sharing.

When to Request an Exception

  • Non-formulary status: Drug isn't covered at all
  • High tier placement: Placed on Tier 4-5 with prohibitive coinsurance
  • Quantity limits: Monthly supply restrictions that don't meet clinical needs
  • Step therapy requirements: Must try other medications first

Required Documentation

Your prescriber should include:

  • Clinical rationale: Why Brensocatib is medically necessary
  • Prior treatment failures: Documentation of inadequate response to standard treatments
  • Contraindications: Medical reasons why alternatives aren't appropriate
  • Exacerbation history: Evidence of 2+ bronchiectasis exacerbations annually
  • Treatment goals: Expected clinical outcomes

Evidence Sources

Strong exception requests cite:

  • FDA approval labeling for BRINSUPRI
  • Clinical trial data from ASPEN and WILLOW studies
  • Pulmonary society guidelines supporting treatment
  • Patient-specific factors requiring this particular therapy

Specialty Pharmacy Requirements

Blue Cross Blue Shield Ohio requires Brensocatib to be dispensed through their approved specialty pharmacy network. Standard retail pharmacies cannot fill these prescriptions for insurance coverage.

Network Options

Anthem Ohio typically contracts with:

  • CarelonRx specialty network
  • BioPlus Exclusive Network pharmacies
  • Designated mail-order specialty services

Dispensing Process

  1. Prescription routing: Your prescriber must send prescriptions directly to an approved specialty pharmacy
  2. Insurance verification: The pharmacy confirms coverage and processes prior authorization
  3. Patient coordination: Specialty pharmacies provide medication counseling and delivery coordination
  4. Ongoing support: Many offer refill reminders and clinical monitoring

Find approved specialty pharmacies through Anthem's provider directory

Appeals on Cost Grounds

If your initial coverage request is denied or approved with unaffordable cost-sharing, Ohio residents have strong appeal rights.

Internal Appeals Process

First-level internal appeal:

  • Timeline: Submit within 60 days of denial
  • Decision timeframe: 15 days for standard, 72 hours for urgent
  • Required elements: Medical necessity documentation, prescriber support letter

Second-level internal appeal:

  • Timeline: Submit within 60 days of first-level denial
  • Review process: Independent medical review by different personnel
  • Documentation: Can include additional clinical evidence and expert opinions

Ohio External Review

After exhausting internal appeals, Ohio residents can request external review through the Ohio Department of Insurance:

  • Eligibility: Medical necessity denials, experimental/investigational determinations
  • Timeline: Request within 180 days of final internal denial
  • Process: Independent Review Organization (IRO) conducts medical review
  • Decision timeframe: 30 days standard, 72 hours expedited
  • Binding result: IRO decisions are binding on the insurer

File external review requests with Ohio Department of Insurance

From our advocates: We've seen cases where patients initially denied specialty drug coverage succeeded on external review by submitting comprehensive clinical documentation showing multiple treatment failures and disease progression. The key is thorough medical record compilation and clear articulation of medical necessity.

Annual Renewal Planning

Benefit Changes to Monitor

Each plan year, review these potential changes:

  • Formulary updates: Drugs can move between tiers or be removed
  • Prior authorization criteria: Requirements may become more or less restrictive
  • Specialty pharmacy networks: Contracted pharmacies can change
  • Cost-sharing structure: Deductibles and coinsurance percentages may adjust

Timing Strategies

  • Late-year initiation: Starting treatment in November-December means lower out-of-pocket costs as you've likely met annual deductibles
  • Early-year budgeting: Plan for higher January-March costs before deductibles are met
  • Manufacturer program renewals: Copay assistance programs typically reset annually and require re-enrollment

Documentation Maintenance

Keep organized records of:

  • Prior authorization approvals and renewal dates
  • Clinical response documentation
  • Insurance correspondence and claim histories
  • Manufacturer assistance program enrollment status

Conversation Scripts

Calling Blue Cross Blue Shield Member Services

"Hello, I'm calling to verify coverage for a specialty medication called Brensocatib, also known as BRINSUPRI. My member ID is [number]. Can you tell me if this drug is on my formulary, what tier it's on, and whether prior authorization is required? I also need to know which specialty pharmacies are in-network for this medication."

Provider Peer-to-Peer Request

"I'm requesting a peer-to-peer review for my patient who needs Brensocatib for non-cystic fibrosis bronchiectasis. The patient has documented recurrent exacerbations despite standard care, and this is the first FDA-approved treatment for their condition. When can we schedule the clinical discussion?"

Specialty Pharmacy Coordination

"I have a prescription for Brensocatib that needs prior authorization processing. Can you help coordinate the PA submission with my insurance and let me know the expected timeline? I'd also like information about any manufacturer assistance programs you can help me access."

FAQ

How long does Blue Cross Blue Shield prior authorization take for Brensocatib in Ohio? Standard prior authorization decisions are typically made within 15 business days. Urgent requests (when delay would seriously jeopardize health) must be decided within 72 hours.

What if Brensocatib is non-formulary on my plan? You can request a formulary exception with supporting clinical documentation. If denied, pursue internal appeals followed by Ohio's external review process through the Department of Insurance.

Can I request an expedited appeal for Brensocatib? Yes, if delays in treatment would seriously endanger your health. Expedited appeals must be decided within 72 hours internally, and expedited external reviews within 72 hours to 7 days depending on circumstances.

Does step therapy apply if I've tried treatments outside Ohio? Medical records from any state should count toward step therapy requirements. Ensure your Ohio provider has complete documentation of prior treatment attempts and outcomes.

What counts as medical necessity for Brensocatib? Typically includes documented non-cystic fibrosis bronchiectasis diagnosis, history of 2+ exacerbations per year, and inadequate response to or contraindications for standard treatments.

How do I find approved specialty pharmacies? Use Anthem Ohio's online pharmacy locator or call member services. Only network specialty pharmacies can fill Brensocatib prescriptions for insurance coverage.

Can Counterforce Health help with my Brensocatib appeal? Counterforce Health specializes in analyzing insurance denials and creating targeted appeals with evidence-backed rebuttals specific to your plan's policies and denial reasons.

This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change over time. Always verify current requirements with your insurer and consult healthcare providers for medical decisions.

Ohio Resources:

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