By Counterforce Health Team in Brensocatib (BRINSUPRI) —

How to Get Brensocatib (BRINSUPRI) Covered by UnitedHealthcare in Illinois: Complete Appeals Guide 2025

Answer Box: Getting Brensocatib Covered by UnitedHealthcare in Illinois

Brensocatib (BRINSUPRI) requires prior authorization from UnitedHealthcare through OptumRx. As Illinois' first-approved DPP1 inhibitor for bronchiectasis, expect initial denials due to step therapy requirements. Your fastest path: 1) Submit PA with documented macrolide failure and airway clearance trial, 2) Request peer-to-peer review if denied, 3) File internal appeal within 180 days citing medical necessity. Illinois provides automatic external review after internal denial with binding decisions within 45 days. Start your appeal with Illinois Department of Insurance guidance.

Table of Contents

  1. Why Illinois State Rules Matter
  2. UnitedHealthcare Prior Authorization Requirements
  3. Step Therapy Protections and Medical Exceptions
  4. Appeals Process: Internal to External Review
  5. Continuity of Care Protections
  6. When to Escalate: State Resources
  7. Scripts and Templates
  8. Common Denial Reasons and Solutions
  9. Frequently Asked Questions

Why Illinois State Rules Matter

Illinois insurance laws provide stronger patient protections than many states, particularly for specialty medications like Brensocatib. The Illinois Health Carrier External Review Act guarantees your right to independent physician review of denials, while new continuity-of-care laws protect ongoing treatments during plan changes.

Key Illinois Advantages:

  • Automatic external review after internal appeal denial (no separate filing required)
  • Binding decisions within 45 days by specialist physicians
  • No cost to consumers for external review
  • 90-day grace period for ongoing treatments during formulary changes (effective 2027)

UnitedHealthcare must follow these state rules for Illinois residents, regardless of whether you have individual, group, or marketplace coverage. However, self-funded employer plans (ERISA) may have different procedures.

UnitedHealthcare Prior Authorization Requirements

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Required through OptumRx UHC Provider Portal
Formulary Status Specialty tier (verify current) Member portal or call customer service
Step Therapy Macrolide trial + airway clearance OptumRx coverage criteria
Quantity Limits Per FDA dosing guidelines Plan-specific
Age Requirements Adults and ≥12 years FDA indication

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Bronchiectasis diagnosis with ICD-10 codes
    • Prior macrolide therapy records and outcomes
    • Airway clearance technique documentation
    • Recent pulmonary function tests and imaging
  2. Submit Initial PA (Clinic)
  3. Request Peer-to-Peer Review (If denied)
    • Physician-to-physician discussion within 24-48 hours
    • Contact OptumRx medical director directly
  4. File Internal Appeal (Within 180 days)
    • Submit via UnitedHealthcare member portal or fax
    • Include additional clinical evidence and specialist letters
  5. External Review (Automatic in Illinois)
    • Independent physician review within 45 days
    • Binding decision on UnitedHealthcare

Step Therapy Protections and Medical Exceptions

Illinois law requires insurers to grant step therapy exceptions when alternatives are contraindicated or have been tried and failed. For Brensocatib, common exceptions include:

Medical Exception Criteria

  • Prior macrolide failure or intolerance (document specific reasons)
  • Contraindications to standard therapies
  • Disease progression despite current treatments
  • Clinical urgency requiring immediate treatment
Clinician Corner: Your medical necessity letter should specifically reference the ASPEN trial data showing 27% reduction in exacerbations compared to placebo, especially if the patient has failed macrolide therapy.

Appeals Process: Internal to External Review

UnitedHealthcare Internal Appeals

Timeline: 15 business days for pre-service requests, 24 hours for expedited

How to File:

  • Online: UnitedHealthcare member portal
  • Phone: Customer service number on your ID card
  • Fax: Appeals department (verify current number)
  • Mail: Address provided in denial letter

Required Documentation:

  • Original denial letter
  • Medical necessity letter from prescriber
  • Clinical notes supporting diagnosis and treatment history
  • Any additional supporting studies or guidelines

Illinois External Review Process

After your internal appeal is denied, Illinois automatically forwards your case for external review unless you opt out. This process is governed by the Illinois Department of Insurance.

Key Features:

  • Independent Review Organization (IRO) assigns a specialist physician
  • 45-day maximum for standard review
  • 72-hour expedited review for urgent cases
  • Binding decision on UnitedHealthcare
  • No cost to you

Continuity of Care Protections

Illinois's new continuity-of-care laws protect patients during plan transitions. If you're already taking Brensocatib and UnitedHealthcare removes it from formulary or changes coverage criteria, you're entitled to:

  • 90-day continued coverage at current cost-sharing (effective 2027)
  • Advance notice of formulary changes
  • Transition assistance to alternative therapies

Counterforce Health helps patients navigate these complex coverage transitions by automatically generating evidence-backed appeals that align with both state protections and payer-specific requirements.

When to Escalate: State Resources

Illinois Department of Insurance

Phone: (877) 527-9431
Website: idoi.illinois.gov

File a complaint if UnitedHealthcare:

  • Violates appeal timelines
  • Fails to follow external review decisions
  • Denies coverage without proper justification

Illinois Attorney General Health Care Bureau

Phone: 1-877-305-5145
Purpose: Direct intervention with insurers for unfair denials

The Attorney General's office can investigate denials and work to recover unfair out-of-pocket expenses, particularly valuable for high-cost medications like Brensocatib.

Scripts and Templates

Patient Phone Script for UnitedHealthcare

"I'm calling about a prior authorization denial for Brensocatib, brand name BRINSUPRI, for bronchiectasis treatment. My doctor documented that I've failed macrolide therapy and meet the FDA-approved indication. I'd like to request a peer-to-peer review with your medical director and understand my appeal options under Illinois law."

Medical Necessity Letter Key Points

Your prescriber should include:

  • Diagnosis: NCF bronchiectasis with ICD-10 codes
  • Prior treatments: Specific macrolides tried, duration, and reasons for failure/intolerance
  • Clinical rationale: Reference to ASPEN trial and FDA approval
  • Monitoring plan: Regular pulmonary function and safety assessments

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Documentation Needed
"Not medically necessary" Cite FDA approval and ASPEN trial Clinical notes, PFTs, imaging
"Step therapy not met" Document macrolide failure Pharmacy records, physician notes
"Experimental/investigational" Reference FDA approval date FDA label, prescribing information
"Quantity limits exceeded" Justify dosing per guidelines Weight-based calculations, specialist letter
From our advocates: We've seen Illinois patients successfully overturn "not medically necessary" denials by submitting comprehensive documentation of failed standard therapies along with references to the drug's FDA approval. The key is demonstrating that conventional treatments have been inadequate while this new therapy addresses an unmet medical need.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Illinois? Standard PA decisions: 5-15 business days. Expedited reviews: 24-72 hours for urgent cases.

What if Brensocatib isn't on UnitedHealthcare's formulary? You can request a formulary exception with medical necessity documentation. Illinois law supports coverage for FDA-approved medications when medically necessary.

Can I appeal if I live in Illinois but have coverage through my employer? Yes, if your employer purchases insurance through UnitedHealthcare. Self-funded ERISA plans may have different procedures.

Does step therapy apply if I failed macrolides in another state? Yes, prior therapy failures from any location count toward step therapy requirements.

How much does Brensocatib cost without insurance? List price is approximately $88,000 annually. Insmed offers patient assistance programs for eligible patients.

What happens if external review upholds the denial? External review decisions are final for state law purposes, though federal appeals may still be available depending on your plan type.

For complex cases involving multiple denials or unique clinical circumstances, platforms like Counterforce Health can help generate targeted appeals that address payer-specific coverage criteria while leveraging Illinois's strong patient protection laws.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance company for personalized guidance. For official Illinois insurance regulations and complaint procedures, contact the Illinois Department of Insurance at (877) 527-9431.

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