By Counterforce Health Team in Brensocatib (BRINSUPRI) —

How to Get Brensocatib (BRINSUPRI) Covered by Cigna in Illinois: PA Forms, Appeals Timeline & Step Therapy Guide

Answer Box: Getting Brensocatib (BRINSUPRI) Covered by Cigna in Illinois

Cigna requires prior authorization for Brensocatib (BRINSUPRI) with specific criteria: age ≥12 years, CT-confirmed bronchiectasis, ≥2 antibiotic-requiring exacerbations in past 12 months (≥1 for ages 12-17), prescription by pulmonologist/ID specialist, and current non-smoker status. Submit via your doctor's office to Cigna PA department. If denied, you have 180 days to appeal internally, then 30 days for Illinois external review. First step today: Have your pulmonologist gather chest CT results, exacerbation history, and complete Cigna's PA form.

Table of Contents

Plan Types & Coverage Implications

Cigna offers multiple plan types in Illinois, each with different referral and network requirements that affect Brensocatib access:

Commercial Plans: HMO plans require primary care referrals to pulmonologists; PPO/EPO plans allow direct specialist access. All require prior authorization for Brensocatib regardless of plan type.

Medicare Advantage: Follows the same PA criteria as commercial plans but may have additional step therapy requirements. Verify your specific plan's formulary at Cigna's drug list portal.

Individual/Family Plans (IFP): Subject to identical PA requirements under policy IP0758, with no state-specific Illinois variations.

Note: All Cigna plans in Illinois route specialty drugs through Express Scripts and Accredo specialty pharmacy network.

Formulary Status & Tier Placement

Brensocatib (BRINSUPRI) requires prior authorization under Cigna's formulary management but doesn't appear on standard tier lists, indicating specialty drug status with likely Tier 3 or 4 placement.

Coverage Verification: Use Cigna's Price a Medication tool to check your specific plan's coverage and identify any PA, step therapy, or quantity limit flags.

Non-Formulary Status: If Brensocatib appears as non-covered, request a formulary exception through the standard exception process with clinical justification.

Prior Authorization Requirements

Cigna's PA criteria for Brensocatib are clearly defined in policy CNF-949:

Coverage Requirements Table

Requirement Details Documentation Needed
Age ≥12 years Birth date verification
Diagnosis Bronchiectasis confirmed by chest CT CT scan report
Exacerbations ≥2 in past 12 months (adults); ≥1 (ages 12-17) requiring antibiotics Medical records with dates, antibiotics used
Prescriber Pulmonologist or infectious disease specialist Provider credentials/NPI
Exclusions No cystic fibrosis; symptoms not primarily COPD/asthma Provider attestation, PFTs if available
Smoking Status Current non-smoker Provider attestation
ICD-10 Codes J47.0, J47.1, or J47.9 Include in PA submission

Step Therapy: Some Cigna plans require documented trial and failure of macrolide antibiotics (like azithromycin) before approving Brensocatib.

Renewal Criteria: After initial 1-year approval, continuation requires demonstrating beneficial response such as reduced exacerbations, preserved lung function, or decreased antibiotic use.

Specialty Pharmacy Network

Cigna routes Brensocatib through Accredo Specialty Pharmacy, part of the Express Scripts network. This isn't optional—it's required for coverage.

Patient Enrollment Process:

  1. Doctor completes Accredo Prescription & Enrollment Form
  2. Fax both pages to 888.302.1028
  3. Accredo calls patient to arrange delivery and provide medication training
  4. Track status via myCigna app or call 800-803-2523

Illinois-Specific Notes: The enrollment form includes state-specific compliance requirements for Illinois e-prescribing laws under 225 ILCS 65.

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic): Collect chest CT report, exacerbation history with antibiotic details, PFT results if available, smoking history.
  2. Verify Network Specialist (Patient): Ensure your pulmonologist or ID specialist is in Cigna's network using the provider directory.
  3. Submit PA Request (Prescriber): Complete Cigna PA form with all required criteria documentation. Submit via CoverMyMeds portal or fax to specialty PA department.
  4. Await Decision (5-10 business days): Standard PA decisions come within 15 business days; expedited requests within 24-48 hours for urgent cases.
  5. If Approved: Prescription automatically routes to Accredo; patient receives enrollment call within 1-2 business days.
  6. If Denied: Review denial letter for specific reasons; gather additional documentation for appeal within 180 days.
  7. Appeal if Necessary: Submit internal appeal with enhanced clinical documentation; request peer-to-peer review if initial appeal fails.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
Insufficient exacerbation history Provide detailed records showing ≥2 episodes requiring antibiotics with specific dates and treatments
Step therapy not met Document macrolide trial with drug name, dosage, duration, and reason for discontinuation (ineffective/intolerance)
Non-network prescriber Transfer care to in-network pulmonologist or request single-case agreement
Age requirement Verify patient is ≥12 years with birth certificate or medical records
Missing CT confirmation Submit radiology report clearly documenting bronchiectasis findings
From Our Advocates: We've seen cases where initial denials were overturned simply by providing more detailed exacerbation documentation. Keep thorough records of every respiratory infection requiring antibiotics—dates, symptoms, treatments, and outcomes. This composite tip reflects common successful appeal patterns.

Appeals Process in Illinois

Illinois provides strong patient protections for insurance appeals with specific timelines:

Internal Appeals:

  • Deadline: 180 calendar days from denial notice
  • Timeline: Cigna processes within 30 days (24-48 hours for expedited)
  • Submission: Via Cigna Provider Appeal Form or written letter with supporting documentation

Peer-to-Peer Review: Request direct physician-to-physician discussion with Cigna's medical director by calling provider services.

External Review (Illinois-Specific):

  • Deadline: 30 days after final internal denial (stricter than many states' 4-month window)
  • Process: File with Illinois Department of Insurance at (877) 527-9431
  • Timeline: Decision within 30 days; 72 hours for expedited
  • Cost: Free to consumers; binding decision

Illinois Resources:

  • Illinois Department of Insurance Office of Consumer Health Insurance: (877) 527-9431
  • Illinois Attorney General Health Care Helpline: (877) 305-5145

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

Cost-Share Considerations

Brensocatib's reported list price of approximately $88,000 annually makes understanding your cost-sharing crucial:

Typical Cost-Share Structure:

  • Tier 3/4 Specialty: 25-50% coinsurance after deductible
  • Out-of-Pocket Maximum: Illinois ACA plans cap annual costs at $9,450 (individual) / $18,900 (family) for 2025

Financial Assistance Options:

  • Manufacturer Support: Check Insmed's patient assistance programs for copay cards and foundation grants
  • Specialty Pharmacy Programs: Accredo offers financial counseling and assistance program coordination
Tip: Specialty drugs often count toward your out-of-pocket maximum quickly, potentially reducing costs for other medications later in the year.

FAQ

Q: How long does Cigna PA take for Brensocatib in Illinois? A: Standard requests: 5-10 business days. Expedited requests for urgent cases: 24-48 hours. Cigna must respond within 15 business days by law.

Q: What if Brensocatib is non-formulary on my plan? A: Request a formulary exception with clinical documentation showing medical necessity. Use Cigna's exception process form.

Q: Can I get an expedited appeal in Illinois? A: Yes, if delays would seriously jeopardize your health. Both Cigna internal appeals and Illinois external reviews offer expedited pathways with 24-72 hour decisions.

Q: Does step therapy apply if I tried macrolides in another state? A: Yes, documented trials from any location count. Provide complete records showing drug, dose, duration, and outcome.

Q: What happens if I miss the 30-day external review deadline in Illinois? A: Illinois' 30-day deadline is strict. Contact the Illinois Department of Insurance immediately to discuss options—they may consider extenuating circumstances.

Q: Can my primary care doctor prescribe Brensocatib? A: No, Cigna requires prescription by a pulmonologist or infectious disease specialist as part of their PA criteria.

When to Escalate

Contact Illinois regulators if you experience:

  • Unreasonable delays beyond stated timelines
  • Repeated denials without clear clinical rationale
  • Process violations (missing deadlines, inadequate review)

Illinois Department of Insurance: File complaints at insurance.illinois.gov or call (877) 527-9431.

For complex cases involving rare diseases or innovative therapies, organizations like Counterforce Health can help build stronger appeals by identifying the specific denial basis and crafting targeted rebuttals using appropriate clinical evidence and payer-specific workflows.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies and requirements may change. Always verify current information with Cigna directly and consult your healthcare provider for medical decisions. For official Illinois insurance regulations and consumer rights, visit the Illinois Department of Insurance website.

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