By Counterforce Health Team in Brensocatib (BRINSUPRI) —

How to Get Brensocatib (BRINSUPRI) Covered by UnitedHealthcare in North Carolina: Prior Authorization Guide & Appeals Process

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

Eligibility: Patients 12+ with confirmed non-cystic fibrosis bronchiectasis and 2+ exacerbations requiring antibiotics in the past year. Fastest path: Submit prior authorization through UnitedHealthcare Provider Portal with pulmonologist evaluation, documented macrolide failure, and HRCT scan. First step today: Verify your plan type (fully insured vs. self-funded) and confirm OptumRx Specialty Pharmacy network status. If denied, you have 180 days to appeal internally, then 120 days for external review through Smart NC.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. Common Denial Reasons and Solutions
  7. Appeals Process in North Carolina
  8. Renewal and Reauthorization
  9. Quick Reference Checklist
  10. FAQ

What This Guide Covers

This comprehensive guide helps North Carolina patients and their healthcare providers navigate UnitedHealthcare's prior authorization process for Brensocatib (BRINSUPRI), the first FDA-approved treatment for non-cystic fibrosis bronchiectasis. We'll walk you through every step from initial submission to appeals, including North Carolina's unique external review options through Smart NC.

Brensocatib represents a breakthrough for bronchiectasis patients, with clinical trials showing significant reduction in pulmonary exacerbations. However, with an estimated annual cost of $88,000, securing insurance coverage requires careful preparation and documentation.

Who this helps: Patients with UnitedHealthcare coverage in North Carolina, their caregivers, and healthcare providers managing prior authorization submissions and appeals.

Before You Start: Plan Verification

1. Confirm Your Plan Type

Before submitting any prior authorization request, verify whether you have a fully insured or self-funded UnitedHealthcare plan. This affects your appeal rights in North Carolina.

  • Fully insured plans: Eligible for North Carolina's external review process through Smart NC
  • Self-funded employer plans: May not be subject to state external review (unless employer opted in)

Contact UnitedHealthcare Member Services at the number on your insurance card to confirm your plan type.

2. Verify Network Status

Brensocatib must be dispensed through an in-network specialty pharmacy to receive coverage. OptumRx Specialty Pharmacy is typically the preferred network provider for UnitedHealthcare members.

Action step: Log into your UnitedHealthcare member portal to confirm current specialty pharmacy network options and formulary status for Brensocatib.

3. Check Formulary Tier

Brensocatib is classified as a specialty-tier medication due to its high cost and indication for a rare condition. Your out-of-pocket costs will depend on your specific plan's specialty tier copayment or coinsurance structure.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required through OptumRx UnitedHealthcare PA Requirements
Age Requirement 12 years and older FDA Label
Diagnosis Confirmed non-cystic fibrosis bronchiectasis FDA Label
Step Therapy Documented macrolide failure/intolerance OptumRx Policy
Prescriber Pulmonologist preferred UnitedHealthcare Policy
Quantity Limit 30 tablets per 30 days OptumRx Specialty
Dispensing OptumRx Specialty Pharmacy required UnitedHealthcare Specialty Drugs

Gather Required Documentation

Medical Necessity Checklist

Before submitting your prior authorization, ensure you have:

Diagnosis Documentation:

  • High-resolution chest CT (HRCT) scan confirming bronchiectasis
  • ICD-10 codes: J47.0, J47.1, or J47.9
  • Pulmonologist evaluation and treatment notes

Clinical History:

  • Documentation of 2+ pulmonary exacerbations requiring systemic antibiotics in past 12 months (adults)
  • Documentation of 1+ exacerbation requiring systemic antibiotics in past 12 months (adolescents 12-17)
  • Dates and details of each exacerbation episode

Prior Therapy Documentation:

  • Evidence of macrolide antibiotic trial (azithromycin, clarithromycin) for 3-6 months
  • Reason for discontinuation (failure, intolerance, contraindication)
  • Documentation of airway clearance attempts (chest physiotherapy, oscillatory devices)

Exclusion Criteria Verification:

  • Confirm patient is not an active smoker (may require cotinine test)
  • Confirm bronchiectasis is primary diagnosis (not secondary to asthma/COPD)
Tip: Counterforce Health's platform can help identify exactly which clinical evidence your specific UnitedHealthcare plan requires and draft targeted medical necessity letters that align with their criteria. Visit www.counterforcehealth.org to learn more about their evidence-backed appeal services.

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Access the UnitedHealthcare Provider Portal

  • Your healthcare provider should submit the PA request electronically through the UnitedHealthcare Provider Portal
  • Alternative: OptumRx e-PA system with PreCheck automation
  • Phone backup: 888-397-8129 (OptumRx Intake Team)

2. Complete Required Forms

  • UnitedHealthcare Commercial Prior Authorization form
  • Include all supporting clinical documentation
  • Attach medical necessity letter from prescribing pulmonologist

3. Submit Complete Documentation Package Include all items from the documentation checklist above. Incomplete submissions are a leading cause of delays and denials.

4. Request Expedited Review (if applicable) If the patient's condition is medically urgent:

  • Commercial plans: 24-hour decision timeline
  • Medicare plans: 72-hour decision timeline
  • Clearly indicate urgency in submission

Timeline Expectations

  • Standard PA decision: Up to 30 calendar days
  • Expedited review: 24-72 hours depending on plan type
  • Incomplete submissions: May receive request for additional information, extending timeline

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
"Step therapy not completed" Submit documentation of macrolide trial and failure/intolerance with specific dates and clinical notes
"Not medically necessary" Provide detailed exacerbation history, lung function data, and impact on quality of life
"Investigational/experimental" Cite FDA approval date (August 12, 2025) and approved indication
"Non-formulary" Request formulary exception with medical necessity justification
"Insufficient documentation" Resubmit with complete clinical records, HRCT results, and specialist evaluation

Clinician Corner: Medical Necessity Letter Elements

Healthcare providers should include these key elements in medical necessity letters:

  • Problem statement: Confirmed NCFB diagnosis with HRCT evidence
  • Prior treatments: Specific macrolide agents tried, duration, and outcomes
  • Clinical rationale: Why Brensocatib is appropriate (first FDA-approved therapy for NCFB)
  • Guideline citations: Reference FDA labeling and ASPEN trial data
  • Monitoring plan: Dermatologic and dental monitoring per FDA requirements

Appeals Process in North Carolina

Internal Appeals with UnitedHealthcare

Timeline: You have 180 days from denial notice to file internal appeal

Level 1 Internal Appeal:

  • Submit through UnitedHealthcare member portal or by mail/fax
  • Decision within 30 days (standard) or 72 hours (expedited)
  • Include additional clinical evidence and medical necessity letter

Peer-to-Peer Review:

  • Can be requested by your provider
  • Completed within 1 business day
  • Opportunity for direct physician-to-physician discussion

External Review Through Smart NC

If your internal appeals are unsuccessful, North Carolina offers robust external review rights through Smart NC.

Eligibility:

  • Must have fully insured UnitedHealthcare plan
  • Must complete internal appeal process first
  • Denial must be based on medical necessity or similar coverage issue

Timeline:

  • File within: 120 days of final internal denial
  • Standard decision: Within 45 days
  • Expedited review: Within 72 hours for urgent cases

How to File:

  • Contact Smart NC: 1-855-408-1212
  • Submit external review request form via NC Department of Insurance website
  • Smart NC staff can help you complete the application and gather supporting documents

Success Rate: External reviews overturn approximately 42% of specialty medication denials when comprehensive clinical documentation is provided.

From our advocates: We've seen cases where patients initially denied for specialty medications like Brensocatib ultimately received approval through North Carolina's external review process. The key was submitting comprehensive clinical documentation showing the patient met FDA criteria and had exhausted standard therapies. While we can't guarantee outcomes, thorough preparation significantly improves success rates.

When to Escalate

If you encounter persistent issues with UnitedHealthcare's prior authorization process, you can file a complaint with North Carolina insurance regulators:

North Carolina Department of Insurance

  • Consumer Services Division
  • Phone: 1-855-408-1212 (Smart NC)
  • Online complaint portal available

Renewal and Reauthorization

Planning for Renewal

Brensocatib prior authorizations typically require annual renewal. Plan ahead:

Calendar reminder: Set renewal reminder 60-90 days before current authorization expires

Required documentation for renewal:

  • Evidence of positive clinical response (reduced exacerbations)
  • Continued medical necessity
  • Updated pulmonologist evaluation
  • Adherence documentation

Response evidence to include:

  • Exacerbation frequency comparison (before vs. during treatment)
  • Lung function stability or improvement
  • Quality of life improvements
  • Tolerability assessment

Quick Reference Checklist

Before Submitting:

  • Confirm plan type (fully insured vs. self-funded)
  • Verify OptumRx Specialty Pharmacy network
  • Check current formulary status

Required Documentation:

  • HRCT scan confirming NCFB diagnosis
  • ICD-10 code (J47.0, J47.1, or J47.9)
  • Pulmonologist evaluation
  • Exacerbation history (2+ episodes in past year for adults)
  • Macrolide failure/intolerance documentation
  • Medical necessity letter

After Submission:

  • Track submission confirmation
  • Follow up within 2 weeks if no response
  • Prepare appeal documentation if denied

FAQ

How long does UnitedHealthcare prior authorization take in North Carolina? Standard decisions are made within 30 days, while expedited reviews for urgent cases are completed within 24-72 hours depending on your plan type.

What if Brensocatib is non-formulary on my plan? You can request a formulary exception by submitting additional medical necessity documentation showing why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal if my condition is urgent? Yes, if a delay would seriously jeopardize your health, you can request expedited internal appeals (72 hours) and expedited external review through Smart NC (72 hours).

Does step therapy apply if I tried macrolides outside North Carolina? Yes, prior therapy documentation from any state is typically accepted as long as you have complete medical records showing the trial and outcome.

What happens if Smart NC overturns UnitedHealthcare's denial? The decision is binding - UnitedHealthcare must provide coverage within 3 business days of the external review decision.

Are there cost assistance programs for Brensocatib? Contact Insmed, the manufacturer, about patient assistance programs. Some patients may qualify for copay support or foundation grants.

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and crafting point-by-point rebuttals aligned to each plan's requirements. Their platform pulls the right clinical evidence and weaves it into appeals that meet procedural requirements while tracking deadlines and required documentation. For complex cases involving specialty medications like Brensocatib, their evidence-backed approach can significantly improve approval rates.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for specific coverage questions. For additional help with insurance appeals in North Carolina, contact Smart NC at 1-855-408-1212.

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