How to Get Brensocatib (BRINSUPRI) Covered by Cigna in North Carolina: Complete Prior Authorization and Appeal Guide
Answer Box: Getting Brensocatib (BRINSUPRI) Covered by Cigna in North Carolina
Eligibility: Adults and teens ≥12 years with bronchiectasis confirmed by CT scan, plus 1-2 pulmonary exacerbations requiring antibiotics in the past year (age-dependent). Fastest path: Have your pulmonologist submit prior authorization through CoverMyMeds or directly to Cigna, including exacerbation history, CT confirmation, and smoking status. First step today: Contact Cigna at 1-800-88-CIGNA to verify if Brensocatib is on your plan's formulary and request the current PA form. If denied, you have 180 days to appeal internally, then 120 days for external review through North Carolina's Smart NC program.
Table of Contents
- Plan Types & Network Requirements
- Formulary Status & Tier Placement
- Prior Authorization Requirements
- Specialty Pharmacy Process
- Cost-Share Considerations
- Submission Process
- Appeals Playbook for North Carolina
- Common Denial Reasons & Solutions
- When to Escalate
- FAQ
Plan Types & Network Requirements
Your Cigna plan type determines whether you need referrals and affects your specialty drug coverage:
- HMO plans: Require a referral from your primary care physician before seeing a pulmonologist. You must use in-network providers for coverage.
- PPO plans: No referrals needed for specialist visits. You can see out-of-network providers but will pay more.
- EPO plans: No referrals required, but coverage is strictly limited to in-network providers except in emergencies.
Note: All plan types require specialty medications like Brensocatib to be dispensed through designated specialty pharmacies, typically Cigna's Accredo.
Formulary Status & Tier Placement
As of late 2025, Brensocatib (BRINSUPRI) does not appear on current Cigna formulary PDFs, suggesting it may be non-formulary or awaiting tier placement. When added, expect Tier 5 (Specialty Tier) placement due to its high cost (approximately $88,000 annually).
To verify current status:
- Use Cigna's Drug List Search Tool
- Call Cigna Pharmacy Services at 1-800-88-CIGNA
- Check your Evidence of Coverage (EOC)
If non-formulary, you can request a formulary exception by submitting medical documentation supporting the need for Brensocatib over covered alternatives.
Prior Authorization Requirements
Cigna has established a Pulmonary – Brinsupri Prior Authorization Policy with specific clinical criteria:
Required Documentation
| Requirement | Details | Documentation Needed |
|---|---|---|
| Age | Patient must be ≥12 years | Birth date verification |
| Diagnosis | Bronchiectasis confirmed by chest CT | Radiology report |
| Exacerbations | Ages 12-17: ≥1 in past 12 months Ages ≥18: ≥2 in past 12 months |
Medical records showing antibiotic treatment |
| Exclusions | No cystic fibrosis, COPD, or asthma as primary driver | Diagnostic testing, pulmonary function tests |
| Smoking Status | Current non-smoker | Provider attestation |
| Prescriber | Pulmonologist or infectious disease specialist | Provider credentials |
Clinical Documentation Checklist
- CT scan report confirming bronchiectasis
- Documentation of pulmonary exacerbations with dates and antibiotic treatments
- Pulmonary function tests (if available)
- Smoking history and current status
- ICD-10 codes for bronchiectasis (J47.0, J47.1, J47.9)
- Provider attestation of medical necessity
Specialty Pharmacy Process
Brensocatib must be dispensed through Cigna's Accredo specialty pharmacy. Here's the enrollment process:
Step-by-Step Enrollment
- Prescription Submission: Your doctor sends the prescription electronically to Accredo
- Patient Contact: Accredo calls you to collect insurance and clinical information
- Prior Authorization: Accredo submits PA to Cigna (or you can call 877-826-7657 to initiate)
- Approval & Delivery: Once approved, medication is delivered to your home or clinic
- Ongoing Support: Access to pharmacists and nurses for therapy management
Expected Timeline: 5-10 business days for PA review, plus 1-2 days for delivery once approved.
Cost-Share Considerations
For Tier 5 specialty medications, expect:
- Coinsurance: Typically 25-40% of the drug's cost
- Monthly caps: Some plans have specialty drug maximum monthly out-of-pocket limits
- Deductible: May need to meet medical or pharmacy deductible first
Tip: Contact Insmed (Brensocatib's manufacturer) about patient assistance programs that may help with copays.
Submission Process
Electronic Submission (Preferred)
- CoverMyMeds: Most efficient platform for PA submissions
- SureScripts: Alternative electronic platform
- Cigna Provider Portal: Direct submission through Cigna's system
Manual Submission
- Fax: 1-866-873-8279
- Phone: 1-800-88-CIGNA for urgent requests
- Mail: Use address on your specific plan's PA form
Required Forms
Download the appropriate form from Cigna's PA forms page or use the Texas Standard Prior Authorization Request Form if no specific form is available.
Appeals Playbook for North Carolina
If your Brensocatib request is denied, North Carolina offers strong appeal rights:
Internal Appeals (Cigna)
| Level | Timeline to File | Review Time | Decision Maker |
|---|---|---|---|
| First Level | 180 days from denial | 30 days (72 hours expedited) | Cigna medical director |
| Second Level | Automatic if first denied | 30 days | Different Cigna reviewer |
Required Documents:
- Original denial letter
- Medical records supporting medical necessity
- Prescriber letter explaining clinical rationale
- Any new clinical evidence
External Review (Smart NC)
After exhausting Cigna's internal appeals, North Carolina residents can request external review through Smart NC:
- Deadline: 120 days from final internal denial
- Contact: Call 1-855-408-1212 or apply online
- Timeline: 45 days for standard review, 72 hours for expedited
- Cost: Free to patients
- Decision: Binding on Cigna
Smart NC Eligibility:
- Must have state-regulated plan (not self-funded employer plans)
- Denial must be based on medical necessity or experimental treatment determination
- Must complete internal appeals first (unless expedited waiver granted)
Common Denial Reasons & Solutions
| Denial Reason | Solution Strategy |
|---|---|
| "Not medically necessary" | Provide detailed exacerbation history, failed treatments, and pulmonary function decline |
| "Experimental/investigational" | Cite FDA approval (August 2025) and ASPEN trial data |
| "Step therapy not met" | Document trials and failures of macrolides or other standard treatments |
| "Non-formulary" | Request formulary exception with comparative effectiveness data |
| "Quantity limits exceeded" | Provide weight-based dosing rationale and monitoring plan |
When to Escalate
Contact North Carolina Department of Insurance if:
- Cigna doesn't respond within required timeframes
- You suspect unfair claim practices
- External review request is improperly denied
Smart NC Contact: 1-855-408-1212
Clinician Corner: Medical Necessity Letter
When writing appeals, include these key elements:
Medical Necessity Template:Patient presentation: Age, diagnosis, severity markersTreatment history: Prior therapies tried, outcomes, intolerancesClinical rationale: Why Brensocatib is appropriate nowEvidence base: FDA approval, clinical trial data (ASPEN study)Monitoring plan: How you'll track effectiveness and safetyGuidelines: Reference ATS/ERS bronchiectasis guidelines supporting DPP1 inhibition
FAQ
Q: How long does Cigna prior authorization take for Brensocatib? A: Standard PA reviews take up to 30 days. Expedited reviews (for urgent medical needs) are completed within 72 hours.
Q: What if Brensocatib isn't on my Cigna formulary? A: Request a formulary exception by providing clinical documentation showing medical necessity and why covered alternatives are inadequate.
Q: Can I get expedited review in North Carolina? A: Yes, both Cigna internal appeals and Smart NC external reviews offer expedited processes (72 hours) when delays could jeopardize health.
Q: Does step therapy apply if I tried macrolides outside North Carolina? A: Yes, prior treatment history from any location counts. Provide documentation of the trial, duration, and reason for discontinuation.
Q: What's the difference between Cigna's appeal and Smart NC? A: Cigna's internal appeals are the first step (required). Smart NC external review is independent and binding - if they overturn the denial, Cigna must cover the medication.
Q: How much will Brensocatib cost with Cigna coverage? A: As a specialty drug, expect 25-40% coinsurance. With an $88,000 annual list price, monthly out-of-pocket could be substantial unless you have specialty drug caps or assistance programs.
Counterforce Health helps patients and clinicians navigate complex prior authorization and appeal processes for specialty medications like Brensocatib. Our platform analyzes denial letters, identifies the specific coverage criteria, and generates evidence-backed appeals tailored to each payer's requirements. By combining clinical documentation with payer-specific policies and procedural knowledge, we help turn insurance denials into successful approvals. Visit www.counterforcehealth.org to learn how we can support your coverage journey.
The appeals process can feel overwhelming, but North Carolina residents have particularly strong protections through the Smart NC program. Whether you're dealing with a prior authorization requirement or appealing a denial, having the right documentation and understanding the timelines is crucial. Counterforce Health specializes in helping patients compile the clinical evidence and procedural documentation needed for successful appeals, particularly for complex specialty drugs in emerging therapeutic areas.
Sources & Further Reading
- Cigna Brinsupri Prior Authorization Policy
- Cigna Prior Authorization Forms
- North Carolina Smart NC Program
- Cigna Drug List Search
- Cigna Appeals Process
This guide is for informational 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 information. Coverage policies and formularies can change without notice.
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