Pharmacy Prior Authorization Criteria

Brinsupri (brensocatib)

Indications for Prior Authorization

Brinsupri (brensocatib)

• For diagnosis of Non-cystic fibrosis bronchiectasis (NCFB)
  Indicated for the treatment of non-cystic fibrosis bronchiectasis (NCFB) in adult and pediatric patients 12 years of age and older

Criteria

Brinsupri

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Both of the following:
• Diagnosis of non-cystic fibrosis bronchiectasis (NCFB)
AND
• Diagnosis has been confirmed by computed tomographic (CT) scan
AND
• Diagnostic testing confirms patient does not have cystic fibrosis
AND
• Submission of medical records (e.g., chart notes) confirming patient has a clinical history consistent with non-cystic fibrosis bronchiectasis (e.g., chronic cough or sputum production or recurrent respiratory tract infections)
AND
• One of the following:
• If patient is 12 to 17 years of age, patient has had at least one (1) documented pulmonary exacerbation requiring treatment with systemic antibiotics in the previous 12 months [A]
OR
• If patient is 18 years of age or older, patient has had at least two (2) documented pulmonary exacerbations requiring treatment with systemic antibiotics in the previous 12 months [A]
AND
• Patient is 12 years of age and older
AND
• One of the following:
• For patients with co-existing COPD, submission of medical records (e.g., chart notes) or paid claims documenting that the patient is receiving one of the following therapies at maximally tolerated doses:
• Triple therapy (i.e., an inhaled corticosteroid (ICS) [e.g., budenoside], a long-acting muscarinic antagonist (LAMA) [e.g., tiotropium, umeclidinium] and a long-acting beta agonist (LABA) [e.g., salmeterol, arformoterol, formoterol]
• If ICS are contraindicated, a LAMA and a LABA
OR
• For patients with co-existing asthma, submission of medical records (e.g., chart notes) or paid claims documenting that patient is currently being treated with one of the following unless there is a contraindication or intolerance to these medications:
• Both of the following:
• Inhaled corticosteroid (ICS) (e.g., fluticasone propionate)
• Additional asthma controller medication (e.g., leukotriene receptor antagonist [LTRA] e.g., montelukast], long-acting beta-2 agonist [LABA] [e.g., salmeterol], long-acting muscarinic antagonist [LAMA] [e.g., tiotropium])
OR
• One combination ICS/LABA product (e.g., Advair, Breo Ellipta)
AND
• Prescribed by a pulmonologist

Brinsupri

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., stabilization or reduction in number of pulmonary exacerbations)

P & T Revisions

2025-09-12

References

1. Brinsupri Prescribing Information. Insmed Incorporated Bridgewater, NJ 08807. August 2025.
2. Chalmers JD, Burgel PR, Daley CL, et al. Phase 3 Trial of the DPP-1 Inhibitor Brensocatib in Bronchiectasis. N Engl J Med. 2025;392(16):1569-1581. doi:10.1056/NEJMoa2411664

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End Notes

1. In the ASPEN trial, pulmonary exacerbations were defined as worsening of 3 or more of the following major symptoms over 48 hours: increased cough, increased sputum volume or change in sputum consistency, increased sputum purulence, increased breathlessness, decreased exercise tolerance, fatigue and/or malaise, and hemoptysis, resulting in a healthcare provider’s decision to prescribe systemic antibiotics.(1)

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Revision History

• 2025-09-12: New program.

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