By Counterforce Health Team in Brensocatib (BRINSUPRI) —

How to Get Brensocatib (BRINSUPRI) Covered by Blue Cross Blue Shield of North Carolina: Complete Prior Authorization Guide 2025

Answer Box: Getting Brensocatib (BRINSUPRI) Covered in North Carolina

To get Brensocatib (BRINSUPRI) covered by Blue Cross Blue Shield of North Carolina: Submit a prior authorization request documenting failed macrolide therapy (azithromycin/clarithromycin) and airway clearance treatment, plus at least 2 exacerbations requiring antibiotics in the past year (1 for patients 12-17). If denied, file an internal appeal within 180 days, then request external review through North Carolina's Smart NC program within 120 days. Start today: Contact your pulmonologist to gather documentation of prior therapies and exacerbation history.

Table of Contents

When Alternatives Make Sense

Before pursuing Brensocatib (BRINSUPRI) coverage, it's important to understand when formulary alternatives might be appropriate—and when they're not. Blue Cross Blue Shield of North Carolina typically requires step therapy, meaning patients must try preferred alternatives before specialty drugs like Brensocatib are approved.

Alternatives make sense when:

  • You haven't tried long-term macrolide therapy (azithromycin or clarithromycin)
  • Airway clearance therapy hasn't been optimized
  • Your exacerbation history doesn't meet Brensocatib's approval criteria
  • You're looking to reduce out-of-pocket costs while building a case for future approval

Alternatives may not be suitable if:

  • You've already failed or can't tolerate macrolides due to cardiac contraindications, hearing loss, or GI intolerance
  • You have documented nontuberculous mycobacteria (NTM) infection, which contraindicates macrolide monotherapy
  • Your exacerbation rate remains high despite optimized standard care
Note: Counterforce Health helps patients and providers navigate these complex coverage decisions by analyzing denial letters and crafting targeted appeals that address specific payer requirements.

Typical Formulary Alternatives

Long-term Macrolide Antibiotics

Azithromycin and clarithromycin are the most common step therapy requirements before Brensocatib approval. Blue Cross Blue Shield NC typically requires documented trial and failure of these medications.

Coverage considerations:

  • Usually preferred formulary status (lower copay)
  • Require baseline ECG and liver function monitoring
  • Need documentation of NTM testing before initiation
  • Must show inadequate response after 3-6 months of therapy

Airway Clearance Therapies

Chest physiotherapy and oscillatory devices are strongly recommended first-line treatments that insurers expect to be optimized before approving specialty drugs.

Options include:

  • Manual percussion and postural drainage
  • Positive expiratory pressure (PEP) devices
  • High-frequency chest wall oscillation
  • Oscillating PEP devices

Coverage notes:

  • Most devices require prior authorization
  • Need letter of medical necessity from pulmonologist
  • Documentation of ongoing symptoms despite therapy

Inhaled Therapies

Hypertonic saline and inhaled antibiotics may be covered alternatives, especially for patients with chronic Pseudomonas infections.

Considerations:

  • Hypertonic saline: generally well-covered, requires bronchodilator pre-treatment
  • Inhaled antibiotics (tobramycin, aztreonam): specialty tier, require PA
  • Not recommended: rhDNase (contraindicated in bronchiectasis)

Coverage Requirements at a Glance

Requirement What it means Where to find it Source
Prior Authorization Pre-approval needed before dispensing BCBS NC formulary BCBS NC Provider Portal
Step Therapy Must try macrolides first Clinical criteria documents BCBS NC Step Therapy Guidelines
Age Requirement ≥12 years old FDA labeling FDA Approval Letter
Exacerbation History 2+ in past year (1+ for ages 12-17) Clinical documentation Provider records
Failed Therapy Macrolide trial documented Medical records Chart notes
Appeals Deadline 180 days internal, 120 days external State regulations NC DOI External Review

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

Timeline: 1-2 weeks

  • Insurance card and policy details
  • Chest CT confirming bronchiectasis diagnosis
  • Documentation of macrolide trials and outcomes
  • Exacerbation history with antibiotic treatment records
  • Airway clearance therapy attempts

2. Submit Prior Authorization Request (Clinic)

Timeline: Same day

  • Complete BCBS NC prior authorization form
  • Include medical necessity letter with clinical rationale
  • Submit via provider portal or fax
  • Expected response: 5-15 business days

3. Monitor Authorization Status (Patient + Clinic)

Timeline: Weekly follow-up

  • Check BCBS NC member portal for updates
  • Contact provider office for status updates
  • Prepare appeal documentation if denial expected

4. File Internal Appeal if Denied (Patient + Clinic)

Timeline: Within 180 days of denial

  • Submit appeal letter addressing denial reasons
  • Include additional clinical evidence
  • Request peer-to-peer review if available
  • Expected response: 30 days standard, 72 hours expedited

5. Request External Review Through Smart NC (Patient)

Timeline: Within 120 days of final internal denial

  • Complete NC external review form
  • Submit all medical records and documentation
  • Call Smart NC at 855-408-1212 for assistance
  • Expected response: 45 days standard, 4 days expedited

Clinician Corner: Medical Necessity Letter Checklist

Essential elements for Brensocatib prior authorization:

✓ Diagnosis: Confirmed non-cystic fibrosis bronchiectasis with chest CT evidence
✓ Age verification: Patient ≥12 years old
✓ Exacerbation history: Document specific dates, antibiotics used, clinical response
✓ Failed therapies: Detailed macrolide trial history with reasons for discontinuation
✓ Contraindications: Any cardiac, hearing, or GI issues preventing macrolide use
✓ Clinical rationale: How Brensocatib addresses unmet medical need
✓ Monitoring plan: Follow-up schedule and safety assessments
✓ Guideline support: Reference FDA approval and clinical trial data

Exception Strategy for Non-Formulary Coverage

If Brensocatib isn't on your Blue Cross Blue Shield NC formulary, you'll need a formulary exception request. This is separate from but often combined with prior authorization.

Key strategies:

  • Medical necessity focus: Emphasize why formulary alternatives are inadequate
  • Clinical evidence: Include peer-reviewed studies supporting off-label or specialized use
  • Cost-effectiveness: Sometimes argue that preventing exacerbations reduces overall costs
  • Provider expertise: Letters from bronchiectasis specialists carry more weight

Documentation to include:

  • Comprehensive medication history
  • Allergy or intolerance documentation
  • Treatment failure specifics (dates, dosing, duration, outcomes)
  • Quality of life impact assessments
From our advocates: We've seen formulary exceptions succeed when providers clearly document not just that standard therapies failed, but why they failed—whether due to intolerance, inadequate response despite optimal dosing, or contraindications. The more specific the clinical narrative, the stronger the case.

Switching Logistics and Provider Coordination

Transitioning to Brensocatib requires careful coordination between your pulmonologist, pharmacy benefits manager, and often a specialty pharmacy.

Before Switching

Required assessments:

  • Baseline pulmonary function tests
  • Complete blood count and comprehensive metabolic panel
  • Sputum culture to rule out active infections
  • Documentation of current exacerbation rate and severity

During Transition

Monitoring requirements:

  • Regular follow-up appointments (typically monthly initially)
  • Safety labs as specified in FDA labeling
  • Exacerbation tracking and quality of life assessments
  • Coordination with specialty pharmacy for drug delivery

Communication Protocol

  1. Provider-to-PBM: Submit all required forms simultaneously
  2. Provider-to-Pharmacy: Confirm specialty pharmacy network participation
  3. Patient-to-All: Maintain communication log for appeals documentation

Counterforce Health's platform can help coordinate these multiple touchpoints by tracking requirements across different stakeholders and ensuring nothing falls through the cracks.

Re-trying for Brensocatib Later

If your initial request is denied and appeals are unsuccessful, building a stronger case for future approval is crucial.

Document everything during alternative therapy:

  • Exact dates of treatment initiation and any dose adjustments
  • Specific adverse effects or intolerances (with severity ratings)
  • Quantitative measures of treatment failure (exacerbation frequency, hospitalizations)
  • Quality of life impacts using validated questionnaires
  • Any emergency department visits or urgent care needs

Timing for re-application:

  • After documented 3-6 month trial of required alternatives
  • Following significant change in clinical status
  • When new clinical evidence becomes available
  • After insurance plan year changes (formularies may update)

Appeals Playbook for Blue Cross Blue Shield NC

Internal Appeals

Level 1 (Standard):

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for determination
  • Submission: BCBS NC member portal or written appeal
  • Required: Original denial letter, medical records, provider letter

Level 1 (Expedited):

  • When to use: Serious jeopardy to health or life
  • Timeline: 72 hours for determination
  • Submission: Call BCBS NC customer service immediately
  • Required: Physician attestation of urgency

External Review (Smart NC)

Eligibility: After exhausting internal appeals or qualifying for expedited review Deadline: 120 days from final internal denial Cost: Free to consumer Timeline: 45 days standard, 4 days expedited Submission: NC DOI external review form Support: Call Smart NC at 855-408-1212

Success factors:

  • Complete medical documentation
  • Clear medical necessity narrative
  • Evidence that denial contradicts policy language
  • Supporting literature and guidelines

FAQ

How long does Blue Cross Blue Shield NC prior authorization take? Standard PA decisions typically take 5-15 business days. Expedited requests (when health is at risk) must be decided within 72 hours.

What if Brensocatib is non-formulary on my plan? You'll need both a formulary exception and prior authorization. Start with a comprehensive medical necessity letter documenting why formulary alternatives are inadequate.

Can I request an expedited appeal in North Carolina? Yes, if waiting for a standard review would seriously jeopardize your health. Both BCBS NC internal appeals and Smart NC external reviews offer expedited options.

Does step therapy apply if I tried macrolides in another state? Medical records from any provider should count toward step therapy requirements. Ensure your NC provider has complete documentation of prior treatments.

What's the success rate for external reviews in North Carolina? While condition-specific data isn't published, North Carolina's Smart NC program accepts about 61% of external review requests for full evaluation, with decisions based on independent clinical review.

How much does Brensocatib cost without insurance? The reported list price is approximately $88,000 per year. Patient assistance programs may be available through the manufacturer, Insmed.

What happens if Smart NC external review is denied? The external review decision is final and binding. Further options would be limited to legal action or reapplying with new clinical evidence.

Can my doctor request a peer-to-peer review? Many Blue Cross Blue Shield plans offer peer-to-peer reviews where your treating physician can discuss the case directly with the plan's medical director. Check your specific plan's appeal process.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific Blue Cross Blue Shield of North Carolina plan and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals, contact Smart NC at 855-408-1212 or visit the NC Department of Insurance website.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to identify denial reasons and draft point-by-point rebuttals aligned to each plan's specific requirements. Learn more about our coverage advocacy services.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.