Brinsupri Denial

@ursala7
everyone should look into the assistance fund (TAF) for help with The co-pays for Brinsupri. You can find it on the Internet easily and they have easy forms to complete for anyone who has bronchiectasis and needs help with this drug. Even though my insurance approved this drug there would have been an out-of-pocket for me at the beginning of the year and because of the assistance fund I pay no out-of-pocket and I get this drug totally free.

@robot I will pay the Meciare RX rate but do not want to have to pay the full price of about $7,500 a month. That's why I am waiting to see what happens after first denial and then doctor submits his papers. I think that is how it is going.

@robot Good point. The specialty pharmacy did a run-down on my income (as shown on IRS forms) (for a grant), but our income was slightly above the qualifying threshold at least for 2026. I suppose we should have them check each new year. Thank you for the suggestion because if others see this, they will want to check.

@ursala7 My income will most likely be too high for a grant. I just want the medicare approval and will pay the 2K minimum if that is how it works.

@picartist Yes, in July I was prescribed Brinsupri. I didn't have to wait for grant approval (after I was told I wouldn't qualify) the specialty pharmacy charged my credit card what was left of my part D yearly "out of pocket" maximum, which in my case was roughly $2000. They sent the prescription out that day. All of my prescriptions have cost me zero since then.

@ursala7 I got lost in that. So I have been denied, if I buy some and pay $2,000 I will get Brinsupri without an approval from Optimum RX. Something doesn't sound right there. I am not looking for a grant, just medicare RX approval.

@picartist Oh, I wasn't ever denied. I was approve,d . I'm sure you have to be approved for this to count toward your part D out of pocket cap which is why this can be affordable. My pulmonologist got me approved through Medicare. I suppose she had to fill out a questionnaire about my multiple exacerbations and 2 hospitalizations, so there was probably no contest about approval. The only question remaining, was whether I would get a grant to help with that first big co-pay. That's all the grant does, I believe, at least for Medicare recipients. Maybe the grant does more subsidy for younger people, IDK. The specialty pharmacy dealt with my insurance. I have a very low monthly Part D premium (under $5 a month). Boy I was shocked. But I had to pay that first month co pay of $2000, while Humana paid over $5000. This one-time co-pay (basically the entire annual Part D out-of-pocket-cost cap) moved me into stage 3 (Catastrophic) coverage, which means I have no charges for the remainder of the year, on ANY of my drugs - amazing, because a couple of my other drugs aren't cheap either. But at over $7000 a month, who in the world can just buy Brinsupri? Maybe because of that part D cap, Medicare patients are getting approved, whereas younger people on private insurance have a higher chance of denial. I don't know why anyone would be denied, if there is documentation showing the need.

I have Medicare/Tricare for life , I was denied too my doctor made all the appeals , got approved after a month. My co pay was around $85 , ( I did not qualify for the fund) I was shocked my co pay is now $48 . So let your doctor make all the appeals .

Oct 15-Dec 7th is open enrollment for all Medicare Part D plans. Please also check Medicare.gov site to see what drugs are covered there. Login Medicare.gov, then add zip code, and it will process what part D plans are in your area. Then add all your meds to the list of drugs you need. After that the system will process what drugs are covered under which plan. I purchased my Drug part D plan through company broker, who’s website was in ERROR and told me my husbands cancer drug was not covered under part D, any plan. His drug is $12,000/month. When I checked Medicare.gov last year, I found a plan which the broker represented which showed the drug was covered. When I told the broker this, she did a deep dive into her system and found their’s was wrong. And the drug would be covered. Of course, we paid the $2100 out of pocket for the first month and the deductible, and then it was free thereafter. So please do check the Medicare.gov website in addition to your brokers. I was relieved last year. But here we go again to another year of Medicare cuts. Good luck to you all.