Brinsupri — Blue Cross Blue Shield of Kansas

non-cystic fibrosis bronchiectasis (NCFB)

Initial criteria

1. ONE of the following: A. The patient has a diagnosis of bronchiectasis and ALL of the following: 1. The patient has a clinical history consistent with bronchiectasis (e.g., cough, chronic sputum production, recurrent respiratory infections) AND 2. The patient has had computed tomography (CT) to confirm the diagnosis of bronchiectasis AND 3. The patient does NOT have cystic fibrosis, primary or secondary immunodeficiency, non-tuberculous mycobacterial (NTM) disease, allergic bronchopulmonary aspergillosis (ABPA), or tuberculosis AND 4. The patient has had at least two pulmonary exacerbations that required an antibiotic prescription within the past 12 months OR B. The patient has another FDA labeled indication for the requested agent and route of administration AND
2. If the patient has an FDA labeled indication, then ONE of the following: A. The patient's age is within FDA labeling for the requested indication for the requested agent OR B. There is support for using the requested agent for the patient's age for the requested indication AND
3. 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
4. The patient does NOT have any FDA labeled contraindications to the requested agent

1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
2. The patient has had clinical benefit with the requested agent AND
3. 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
4. The patient does NOT have any FDA labeled contraindications to the requested agent

12 months