By Counterforce Health Team in Brensocatib (BRINSUPRI) —

How to Get Brensocatib (BRINSUPRI) Covered by UnitedHealthcare in Michigan: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting BRINSUPRI Covered in Michigan

Brensocatib (BRINSUPRI) requires prior authorization through UnitedHealthcare's OptumRx with documented non-cystic fibrosis bronchiectasis, age 12+, ≥2 exacerbations yearly, and failed macrolide trial. Submit via the UnitedHealthcare Provider Portal or fax to 1-844-403-1027. If denied, you have 180 days for internal appeals, then 127 days for Michigan DIFS external review. Start today: Verify your formulary tier and gather CT scan results showing bronchiectasis diagnosis.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. If Asked for More Information
  7. Appeals Process in Michigan
  8. Renewal and Reauthorization
  9. Quick Reference Checklist
  10. FAQ

What This Guide Covers

This guide helps Michigan patients and their healthcare providers navigate UnitedHealthcare's prior authorization process for Brensocatib (BRINSUPRI), the first FDA-approved treatment for non-cystic fibrosis bronchiectasis. Whether you're facing an initial coverage request or appealing a denial, we'll walk through each step with forms, timelines, and scripts specific to Michigan's insurance laws.

Who this helps: Adult and pediatric patients (12+) with confirmed bronchiectasis, their caregivers, and healthcare teams managing UnitedHealthcare coverage in Michigan.

Before You Start: Verify Your Coverage

Step 1: Check Your Plan Type and Formulary Status

Log into your UnitedHealthcare member portal to verify:

  • Plan type: Commercial, Medicare Advantage, or Medicaid managed care
  • Formulary tier: BRINSUPRI's coverage level and copay
  • Pharmacy benefit: Confirm OptumRx manages specialty medications
Note: Self-funded employer plans may have different coverage policies than standard UnitedHealthcare plans.

Step 2: Confirm In-Network Prescriber

BRINSUPRI requires a specialist prescriber, preferably a pulmonologist. Verify your doctor is in-network through the member portal to avoid coverage complications.

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Diagnosis Non-cystic fibrosis bronchiectasis (ICD-10: J47.0, J47.1, J47.9) HRCT scan, pulmonologist notes OptumRx PA Form
Age 12 years and older Patient demographics FDA Label
Exacerbations ≥2 per year requiring antibiotics Medical records with dates, treatments UHC PA Requirements
Step Therapy Failed macrolide antibiotics Trial records: azithromycin, clarithromycin, erythromycin OptumRx Guidelines
Quantity Limit 30 tablets per 30 days Prescription matches FDA dosing FDA Prescribing Information

Gather Required Documentation

Essential Documents Checklist

Patient Information:

  • Insurance card and member ID
  • Photo ID
  • Complete contact information

Medical Records:

  • High-resolution CT scan confirming bronchiectasis
  • Pulmonology consultation notes (within 30 days)
  • Exacerbation history with specific dates and antibiotic treatments
  • Pulmonary function tests (PFTs)

Prior Treatment Documentation:

  • Macrolide antibiotic trials with:
    • Medication names and doses
    • Treatment duration
    • Reason for discontinuation (ineffective, intolerance, contraindication)
    • Clinical response or lack thereof

Supporting Clinical Evidence:

  • Medical necessity letter from prescribing physician
  • Monitoring plan for dermatologic and dental side effects
  • Current medication list
  • Smoking status documentation (non-smoker required)

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Access the Submission Portal Your prescriber can submit through:

2. Complete the PA Request Form Use the OptumRx General PA Form and include:

  • Patient demographics and insurance information
  • Diagnosis codes (ICD-10: J47.0, J47.1, or J47.9)
  • Medication details: Brensocatib 10mg or 25mg, once daily
  • Clinical justification referencing ASPEN trial data

3. Attach Supporting Documentation

  • Medical necessity letter
  • Recent clinical notes (≤30 days)
  • CT scan results
  • Exacerbation log
  • Prior macrolide trial records
  • Monitoring plan outline

4. Request Expedited Review (If Applicable) For urgent cases where health would be jeopardized by delay, request expedited review (24-72 hours) with physician documentation of medical urgency.

Medical Necessity Letter Components

Clinician Corner: Essential Elements

Your medical necessity letter should address:

  1. Patient Problem Statement
    • Confirmed bronchiectasis diagnosis via HRCT
    • Frequency and severity of exacerbations
    • Impact on quality of life and daily functioning
  2. Prior Treatment History
    • Specific macrolides tried, doses, and duration
    • Clinical response and reasons for discontinuation
    • Other supportive therapies attempted
  3. Clinical Rationale for BRINSUPRI
    • Reference ASPEN trial showing 27% reduction in exacerbations
    • Patient-specific factors supporting treatment choice
    • Expected clinical outcomes
  4. Safety Monitoring Plan
    • Dermatologic monitoring per FDA guidelines
    • Dental health assessment plan
    • Follow-up schedule

Follow-Up and Timeline Expectations

Standard Processing Times

  • Initial determination: 30 days maximum for non-urgent requests
  • Expedited review: 72 hours for urgent medical needs
  • Additional information requests: 14 days to respond

Follow-Up Best Practices

Week 1: Call OptumRx at 888-397-8129 to confirm receipt and obtain reference number.

Week 2-3: Check status through provider portal or call for updates.

Sample follow-up script: "I'm calling to check the status of prior authorization request #[reference number] for patient [name] submitted on [date]. Can you provide an update on the review timeline?"

Tip: Document all phone calls with date, time, representative name, and reference numbers for your records.

If Asked for More Information

UnitedHealthcare may request additional documentation to support medical necessity. Common requests include:

Handling Information Requests

Clinical Clarification:

  • Provide detailed exacerbation history with hospitalization records
  • Submit recent pulmonary function test results
  • Include quality of life assessments

Literature Support:

Peer-to-Peer Review: If requested, prepare your physician for a clinical discussion with UnitedHealthcare's medical director. Key talking points:

  • Patient's specific clinical presentation
  • Why standard treatments failed
  • Expected benefits from BRINSUPRI therapy

Appeals Process in Michigan

Internal Appeals with UnitedHealthcare

Timeline: 180 days from denial date

Step 1: File Internal Appeal Submit through:

  • UnitedHealthcare member portal
  • Written appeal to address on denial letter
  • Phone: Member services number on insurance card

Required Documentation:

  • Original denial letter
  • Additional medical records
  • Updated medical necessity letter
  • ASPEN trial data supporting efficacy

Michigan External Review Process

Timeline: 127 days after final internal denial

Step 2: File with Michigan DIFS After exhausting internal appeals, file an external review with the Michigan Department of Insurance and Financial Services.

Submission Options:

  • Online: DIFS External Review Form
  • Mail: DIFS, Office of General Counsel – Appeals Section, P.O. Box 30220, Lansing, MI 48909-7720
  • Phone assistance: 877-999-6442

Expedited External Review: Available within 72 hours if physician confirms delay would jeopardize health.

Note: Michigan's external review decisions are binding on UnitedHealthcare and typically completed within 60 days.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Not medically necessary Submit ASPEN trial data showing 27% exacerbation reduction Peer-reviewed study, FDA approval rationale
Step therapy not met Document macrolide failures with specific reasons Treatment records, intolerance documentation
Quantity limits exceeded Justify dosing per FDA label Prescribing information, physician rationale
Non-formulary status Request formulary exception Medical necessity letter, alternative failure proof

Renewal and Reauthorization

Annual Reauthorization Requirements

Submit renewal requests 60-90 days before current authorization expires. Include:

Response Evidence:

  • Reduced exacerbation frequency
  • Stable or improved lung function
  • Treatment adherence documentation
  • Continued medical necessity

Updated Clinical Data:

  • Recent pulmonary function tests
  • Exacerbation log from treatment period
  • Current clinical assessment
  • Safety monitoring results

Patient Assistance and Cost Support

Counterforce Health helps patients navigate complex prior authorization and appeals processes by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and drafts point-by-point rebuttals aligned with payer-specific policies, potentially saving months of back-and-forth with insurers.

Additional Support Options:

  • Insmed patient assistance programs (verify eligibility at manufacturer website)
  • State pharmaceutical assistance programs
  • Foundation grants for rare disease treatments

Quick Reference Checklist

Before Submitting PA:

  • Verify UnitedHealthcare formulary status
  • Confirm in-network prescriber
  • Gather CT scan confirming bronchiectasis
  • Document ≥2 exacerbations in past year
  • Obtain macrolide trial failure records
  • Prepare medical necessity letter
  • Complete monitoring plan

Submission Process:

  • Submit via provider portal or fax 1-844-403-1027
  • Obtain confirmation and reference number
  • Follow up within one week
  • Respond to information requests within 14 days

If Denied:

  • File internal appeal within 180 days
  • Gather additional supporting evidence
  • Consider peer-to-peer review
  • File Michigan DIFS external review within 127 days of final denial

FAQ

How long does UnitedHealthcare PA take for BRINSUPRI in Michigan? Standard review takes up to 30 days. Expedited review for urgent cases is completed within 72 hours.

What if BRINSUPRI is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal in Michigan? Yes, if your physician confirms that waiting would jeopardize your health. Michigan DIFS offers 72-hour expedited external review.

Does step therapy apply if I failed macrolides outside Michigan? Yes, document out-of-state treatment failures with specific medications, doses, duration, and reasons for discontinuation.

What's the difference between pharmacy and medical benefit coverage? BRINSUPRI is typically covered under pharmacy benefit through OptumRx. Verify your specific plan's coverage pathway in the member portal.

How much does BRINSUPRI cost without insurance? List price is approximately $88,000 annually. Patient assistance programs may be available through the manufacturer.

From our advocates: We've seen patients successfully appeal BRINSUPRI denials by including detailed exacerbation logs with specific dates, antibiotic courses, and hospitalizations. This concrete evidence helps medical reviewers understand the severity of the condition and need for targeted therapy. While outcomes vary, thorough documentation significantly strengthens appeals.

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage policies vary by plan and may change. Consult your healthcare provider for medical decisions and contact Counterforce Health for personalized appeals assistance. For official Michigan insurance appeal information, visit the Michigan Department of Insurance and Financial Services.

Sources & Further Reading

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