By Counterforce Health Team in Brensocatib (BRINSUPRI) —

Myths vs. Facts: Getting Brensocatib (BRINSUPRI) Covered by Humana in New York

Quick Answer: Getting Brensocatib Covered by Humana in New York

Brensocatib (BRINSUPRI) requires prior authorization from Humana Medicare Advantage plans and typically involves step therapy with macrolide antibiotics first. Your fastest path: gather documentation of ≥2 exacerbations per year, failed macrolide trials, and bronchiectasis diagnosis. Submit via Humana's provider portal with a detailed medical necessity letter. If denied, you have 65 days to appeal internally, then can request New York's external review through DFS within 180 days. Start today: Contact your prescriber to begin collecting your treatment history and exacerbation records.

Table of Contents

Why Myths About Brensocatib Coverage Persist

Brensocatib (BRINSUPRI) became the first FDA-approved treatment specifically for non-cystic fibrosis bronchiectasis in August 2025. With this groundbreaking approval came confusion about insurance coverage—especially among patients who assumed that FDA approval automatically means insurance coverage.

The reality is more complex. At roughly $88,000 per year, Brensocatib faces the same utilization management hurdles as other specialty medications. Humana, like most insurers, has implemented strict prior authorization protocols and step therapy requirements.

These myths persist because patients and even some healthcare providers are still learning how specialty drug coverage works, particularly for newly approved treatments. Let's separate fact from fiction.

Top 8 Myths vs. Facts About Coverage

Myth 1: "If my doctor prescribes Brensocatib, Humana has to cover it"

Fact: Humana requires prior authorization for all specialty medications, including Brensocatib. Your prescription alone isn't enough—your doctor must submit detailed clinical documentation proving medical necessity.

Myth 2: "FDA approval means automatic insurance coverage"

Fact: FDA approval establishes safety and efficacy, but insurers make separate coverage decisions based on their own criteria. Humana evaluates cost-effectiveness, clinical guidelines, and whether less expensive alternatives exist.

Myth 3: "I can skip trying other treatments first"

Fact: Humana typically requires step therapy with macrolide antibiotics before approving Brensocatib. You must document failed trials or contraindications to azithromycin, clarithromycin, or other standard treatments.

Myth 4: "Having bronchiectasis is enough to get approved"

Fact: You need documented evidence of ≥2 exacerbations per year despite standard care. Current guidelines recommend Brensocatib specifically for patients with frequent exacerbations who haven't responded adequately to other treatments.

Myth 5: "If I'm denied, there's nothing I can do"

Fact: New York has some of the strongest patient appeal rights in the nation. You can appeal internally with Humana, then request an external review through the Department of Financial Services where independent specialists review your case.

Myth 6: "My previous insurance covered it, so Humana will too"

Fact: Each insurer has different formularies and coverage criteria. Previous coverage doesn't guarantee approval with a new plan, though it can serve as supporting evidence in your appeal.

Myth 7: "Generic alternatives work just as well"

Fact: There are currently no generic versions of Brensocatib, and no other drugs are specifically approved for non-cystic fibrosis bronchiectasis. Macrolides are used off-label but have different mechanisms of action.

Myth 8: "The appeals process takes forever"

Fact: Humana must respond to standard appeals within 7 days for Part D medications. Expedited appeals get 24-hour decisions when your health is at risk.

What Actually Influences Humana's Approval Decision

Understanding what Humana's reviewers actually look for can dramatically improve your chances of approval:

Clinical Documentation Requirements

  • Confirmed diagnosis: CT scan showing bronchiectasis
  • Exacerbation history: At least 2 documented pulmonary exacerbations in the past 12 months
  • Treatment failures: Records of inadequate response to or contraindications for macrolide antibiotics
  • Functional impact: Pulmonary function tests, symptom scores, or quality of life measures

Medical Necessity Letter Elements

Your prescriber's letter should address:

  1. Why standard treatments haven't worked or aren't appropriate
  2. How Brensocatib specifically addresses your clinical needs
  3. Expected outcomes and monitoring plan
  4. Reference to current bronchiectasis treatment guidelines

Formulary Considerations

Brensocatib is likely placed on Humana's highest specialty tier, but formulary exception processes exist for non-formulary drugs when medically necessary.

From our advocates: "We've seen the strongest approvals when patients can show a clear timeline—diagnosis date, specific exacerbations with dates and treatments, and documented failures of at least two macrolide trials with specific drugs, doses, and outcomes. The more specific your records, the harder it becomes for reviewers to deny based on 'insufficient documentation.'"

5 Costly Mistakes to Avoid

1. Submitting Incomplete Documentation

Don't rely on your prescriber to know exactly what Humana needs. Proactively gather your complete medical history, including records from other providers who may have treated your exacerbations.

2. Missing Appeal Deadlines

You have 65 days from Humana's denial notice to request an internal appeal. Missing this deadline forfeits your right to challenge the decision.

3. Not Requesting Expedited Review When Appropriate

If delaying Brensocatib could seriously harm your health, request an expedited appeal. Humana must decide within 24 hours for urgent cases.

4. Failing to Document Step Therapy Compliance

Even if you tried macrolides with a previous doctor or insurance plan, you need documented proof. Contact former providers to obtain these records before submitting your request.

5. Not Leveraging New York's Appeal Rights

Many patients don't realize they can request an external review through New York's Department of Financial Services after exhausting Humana's internal process. This independent review often favors patients when clinical evidence supports medical necessity.

Your 3-Step Action Plan

Step 1: Gather Your Documentation (This Week)

  • Request complete medical records from all providers who've treated your bronchiectasis
  • Compile a chronological list of exacerbations with dates, symptoms, and treatments
  • Obtain copies of CT scans, pulmonary function tests, and culture results
  • Document all previous medication trials, including specific drugs, doses, durations, and outcomes

Step 2: Work with Your Prescriber (Next 1-2 Weeks)

  • Schedule a dedicated appointment to discuss the prior authorization process
  • Review Humana's specific requirements together
  • Ensure your prescriber understands the need for a detailed medical necessity letter
  • Submit the complete package via Humana's provider portal or fax to 877-486-2621

Step 3: Prepare for Potential Appeals (Ongoing)

  • Monitor your Humana member portal for status updates
  • If denied, immediately begin gathering additional supporting evidence
  • Consider consulting with Counterforce Health for specialized appeal assistance
  • Know your New York appeal rights and deadlines

New York Appeal Rights

New York residents have particularly strong protections when fighting insurance denials:

Internal Appeals with Humana

  • Timeline: 65 days from denial notice to request appeal
  • Decision: 7 days for standard Part D appeals
  • Expedited: 24 hours when health is at risk

External Review Through DFS

After exhausting Humana's internal appeals:

  • Timeline: 180 days to request external review (expanded from 60 days in 2025)
  • Process: Independent clinical specialist reviews your case
  • Cost: Free to patients
  • Decision: Binding on Humana
  • Success rate: Nearly 60% of denials are overturned during peer-to-peer or external review

Getting Help

  • Healthcare Appeals Ombudsman: 1-800-NYS-APPEAL
  • Community Health Advocates: 888-614-5400 (free counseling)
  • DFS Online Portal: Submit appeals electronically

Resources and Next Steps

Essential Forms and Contacts

Professional Support

When facing complex denials or appeals, consider working with specialists who understand the intricacies of insurance coverage for rare and specialty medications. Counterforce Health helps patients, clinicians, and pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed responses that align with each payer's specific requirements.

Additional Resources

FAQ

How long does Humana take to decide on Brensocatib prior authorization? Standard decisions take up to 72 hours. Expedited requests (when health is at risk) get 24-hour decisions.

What if Brensocatib isn't on Humana's formulary? You can request a formulary exception with supporting medical documentation. The process is the same as prior authorization but requires additional justification for non-formulary coverage.

Can I get temporary coverage while waiting for approval? Humana may provide a temporary supply in certain circumstances, particularly if you're transitioning from another plan or are in a nursing facility.

Do I need to see a specialist to get approved? While not always required, having a pulmonologist's support can strengthen your case, especially for the medical necessity letter.

What happens if I move to another state? Coverage decisions typically transfer within the same Humana plan, but appeal rights and external review processes vary by state.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For official information about New York insurance appeals, visit the Department of Financial Services website.

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