brensocatib — Blue Cross Blue Shield of Alabama

other FDA labeled indications for the requested agent and route of administration

Initial criteria

ONE of the following:
- The patient has a diagnosis of bronchiectasis and ALL of the following:
• The patient has a clinical history consistent with bronchiectasis (e.g., cough, chronic sputum production, recurrent respiratory infections)
• The patient has had computed tomography (CT) to confirm the diagnosis of bronchiectasis
• The patient does NOT have cystic fibrosis, primary or secondary immunodeficiency, non-tuberculous mycobacterial (NTM) disease, allergic bronchopulmonary aspergillosis (ABPA), or tuberculosis
• The patient has had at least two pulmonary exacerbations that required an antibiotic prescription within the past 12 months
- OR the patient has another FDA labeled indication for the requested agent and route of administration
AND if the patient has an FDA labeled indication, then ONE of the following:
• The patient's age is within FDA labeling for the requested indication for the requested agent
• OR there is support for using the requested agent for the patient's age for the requested indication
AND the prescriber is a specialist in the area of the patient’s diagnosis (e.g., pulmonologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
AND the patient does NOT have any FDA labeled contraindications to the requested agent

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
AND the patient has had clinical benefit with the requested agent
AND the prescriber is a specialist in the area of the patient’s diagnosis (e.g., pulmonologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
AND the patient does NOT have any FDA labeled contraindications to the requested agent

12 months