By Counterforce Health Team in Brensocatib (BRINSUPRI) —

Myths vs. Facts: Getting Brensocatib (BRINSUPRI) Covered by Aetna (CVS Health) in New Jersey

Answer Box: Getting BRINSUPRI Covered by Aetna in New Jersey

Brensocatib (BRINSUPRI) is covered by Aetna (CVS Health) in New Jersey through prior authorization when you meet specific criteria: age 12+, confirmed non-CF bronchiectasis, ≥2 exacerbations in 12 months, and documented macrolide antibiotic failure. Submit PA via CVS Caremark provider portal with required documentation. If denied, file internal appeal within 180 days, then external review through New Jersey's IHCAP program within 4 months. Start today: verify your formulary tier and gather macrolide trial records.

Table of Contents

  1. Why These Myths Persist
  2. Common Myths About BRINSUPRI Coverage
  3. What Actually Influences Approval
  4. Avoid These Preventable Mistakes
  5. Your 3-Step Action Plan
  6. Resources and Next Steps

Why These Myths Persist

When Brensocatib (BRINSUPRI) launched in August 2025 as the first FDA-approved treatment specifically for non-cystic fibrosis bronchiectasis, confusion about insurance coverage spread quickly. With an $88,000 annual list price and complex prior authorization requirements, patients and even some healthcare providers developed misconceptions about who qualifies and how the approval process works.

These myths often stem from incomplete information about Aetna's coverage policies, misunderstanding of New Jersey's appeal rights, or confusion between different types of insurance plans. Let's separate fact from fiction.

Common Myths About BRINSUPRI Coverage

Myth #1: "BRINSUPRI is automatically denied by Aetna"

Fact: Aetna covers BRINSUPRI through prior authorization when medical necessity criteria are met. The drug is included on Aetna's 2026 formulary lists and not on exclusion lists, meaning coverage is available with proper documentation.

Myth #2: "You need to fail every possible treatment first"

Fact: Aetna's step therapy requirement is specific: documented trial and failure of macrolide antibiotics (like azithromycin) plus airway clearance therapy. You don't need to exhaust every bronchiectasis treatment available—just meet the specific criteria outlined in their policy.

Myth #3: "Only pulmonologists can prescribe BRINSUPRI"

Fact: While Aetna prefers pulmonologists or infectious disease specialists, the policy doesn't absolutely require specialist prescribing. However, having a specialist involved significantly strengthens your prior authorization request and appeal chances.

Myth #4: "If my internal appeal fails, I'm out of options"

Fact: New Jersey offers one of the nation's strongest external review programs. After completing Aetna's internal appeals, you can file for external review through New Jersey's IHCAP program, administered by Maximus Federal Services. This independent review is binding on Aetna and free to you.

Myth #5: "Medicare patients can't get coverage"

Fact: BRINSUPRI is covered under Medicare Part D and Medicare Advantage plans, including Aetna Medicare plans. Medicare patients benefit from the $2,000 annual out-of-pocket cap, making the medication more affordable once you reach that threshold.

Myth #6: "The copay assistance program doesn't work with insurance"

Fact: Insmed's BRINSUPRI Copay Savings Program can reduce your monthly cost to $0 for commercially insured patients. Call inLighten at 833-544-4800 to verify eligibility. Note: This program excludes government insurance (Medicare, Medicaid).

Myth #7: "You need multiple hospitalizations to qualify"

Fact: Aetna's criteria require ≥2 pulmonary exacerbations in the past 12 months, which can include outpatient events (increased cough, sputum, breathlessness for ≥48 hours). Hospitalizations aren't mandatory—documented exacerbations treated in any setting count.

Myth #8: "Appeals take forever and rarely succeed"

Fact: New Jersey's external review process moves efficiently: preliminary review within 5 business days, final decision within 45 days (expedited cases much faster). While specific success rates aren't published, external reviews nationwide favor patients in approximately half of cases.

What Actually Influences Approval

Understanding Aetna's actual decision-making process helps you submit stronger requests:

Coverage Criteria That Matter

  • Age requirement: 12 years or older
  • Confirmed diagnosis: High-resolution CT scan showing bronchiectasis
  • Exacerbation history: ≥2 documented episodes in past 12 months
  • Prior therapy failure: Macrolide antibiotic trial with documented failure or intolerance
  • Exclusions: No cystic fibrosis, primary immunodeficiency, or active NTM infection

Documentation Quality

Strong prior authorization requests include:

  • Clinical notes within 30 days describing current symptoms
  • Macrolide trial records showing specific drug, dose, duration, and reason for discontinuation
  • Exacerbation documentation with dates, symptoms, and treatments
  • CT scan reports confirming bronchiectasis pattern
  • Letter of medical necessity from prescriber citing FDA approval and clinical trials

Routing and Timing

Submit through CVS Caremark's provider portal or call the specialty pharmacy line at 866-814-5506. Standard reviews take 30 days; expedited reviews (when delay could jeopardize health) are completed within 72 hours.

From Our Advocates: We've seen denials overturned when providers included specific details about macrolide failures—not just "patient tried azithromycin" but "patient completed 6-month azithromycin course with persistent exacerbations and GI intolerance requiring discontinuation." Specific documentation makes the difference.

Avoid These Preventable Mistakes

1. Submitting Incomplete Prior Authorization

The Problem: Missing key documentation like CT scan reports or vague statements about prior therapy. The Fix: Use Aetna's Medical Exception/PA form as a checklist and attach all supporting documents.

2. Not Requesting Expedited Review When Appropriate

The Problem: Waiting 30 days for standard review when patient's condition warrants faster decision. The Fix: If exacerbations are frequent or severe, mark "urgent" on the PA form and provide clinical justification.

3. Giving Up After First Denial

The Problem: Accepting initial denial without understanding appeal rights. The Fix: File internal appeal within 180 days, then external review through IHCAP if needed.

4. Missing Appeal Deadlines

The Problem: Not tracking important dates for internal appeals (180 days) or external review (4 months from final denial). The Fix: Calendar all deadlines immediately upon receiving any denial letter.

5. Not Engaging with Available Support

The Problem: Navigating the process alone when help is available. The Fix: Contact Insmed's inLighten program (833-544-4800) for coverage support and Counterforce Health for appeal assistance.

Your 3-Step Action Plan

Step 1: Verify Coverage and Requirements (Do Today)

  • Log into your Aetna member portal or call member services to confirm BRINSUPRI's formulary status
  • Download Aetna's prior authorization form
  • Check if your prescriber is enrolled with CVS Caremark

Step 2: Gather Required Documentation (This Week)

  • Request copies of your CT scan reports showing bronchiectasis
  • Collect records of macrolide antibiotic trials (drug names, dates, outcomes)
  • Document all exacerbations in the past 12 months with dates and treatments
  • Schedule appointment with pulmonologist if not already seeing one

Step 3: Submit Strong Prior Authorization (Within 2 Weeks)

  • Work with your prescriber to complete the PA form thoroughly
  • Include letter of medical necessity citing FDA approval and clinical need
  • Submit via CVS Caremark provider portal or specialty pharmacy line
  • Request expedited review if clinically appropriate

Resources and Next Steps

Official Coverage Information

New Jersey Appeal Support

  • IHCAP External Review: njihcap.maximus.com or 888-866-6205
  • NJ Department of Banking and Insurance: 888-393-1062
  • Consumer Hotline: 800-446-7467

Patient Assistance

  • BRINSUPRI Copay Program: 833-544-4800
  • Patient Access Network Foundation: For those ineligible for manufacturer programs
  • HealthWell Foundation: Grants for specialty medications

Professional Support

Organizations like Counterforce Health specialize in turning insurance denials into successful appeals by providing targeted, evidence-backed documentation that aligns with payer policies. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes more effectively.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and may change. Always verify current requirements with your insurer and consult your healthcare provider about appropriate treatment options.

Sources & Further Reading

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