Brinsupri (brensocatib tablets – Insmed) — Cigna

Initial criteria

• Patient is ≥ 12 years of age; AND
• Patient has a history of bronchiectasis as diagnosed by chest computed tomography; AND
• Patient meets ONE of the following (a or b):
• a) Patient is ≥ 12 years of age and < 18 years of age: Patient has had at least one pulmonary exacerbation in the last 12 months that resulted in the prescription of an antibiotic agent; OR
• b) Patient is ≥ 18 years of age: Patient has had at least two pulmonary exacerbations in the last 12 months that resulted in the prescription of an antibiotic agent; AND
• According to the prescriber, respiratory symptoms are not driven primarily by chronic obstructive pulmonary disease or asthma; AND
• Patient does not have cystic fibrosis; AND
• According to the prescriber, patient is a current non-smoker; AND
• The medication is prescribed by or in consultation with a pulmonologist or infectious disease physician

Reauthorization criteria

• Patient is ≥ 12 years of age; AND
• Patient does not have cystic fibrosis; AND
• According to the prescriber, patient is a current non-smoker; AND
• According to the prescriber, patient has experienced a beneficial clinical response (e.g., reduction in number of exacerbations, preservation of lung function, reduced cough, reduced sputum production, or less shortness of breath); AND
• The medication is prescribed by or in consultation with a pulmonologist or infectious disease physician

Approval duration

1 year