Brinsupri Denial

Was it submitted by pulmonary? They should know how to complete the prior authorization paperwork so it is successful.

@scoop There is a pharmacy rep, I think, that texts me and handles the doctor's request for Brinsupri. I had one denial and then my doctor has submitted the reports, etc. Is there then a second and maybe third denial? Is the first one pretty usually always denied as a routine for Optimum RX?

@picartist
Sorry I don’t know about OptumRx.

@picartist Yep, Optum's SOP (standard operating procedure) is to deny first. There has been a lot of publicity about it.
With a different Rx, I had to do 2 appeals - my cardiologist's office handled it.
We went through a similar situation with my partner and a diabetes drug, also ultimately approved.
Are you on Medicare? They have very specific timelines for the indurer to respond, and you can also appeal to them.
PS Optum is another "Arm" of the for-profit United Health Corporation.

Sorry, I had Optum Rx/UHC last year. Worst, worst PDP…. Fought with them for first 6 months of year. However, you can get through it, it will take a lot of perseverance. It’s a new drug. So you will probably need Prior Authorization, meaning paperwork from your specialist. You can get Rx’s through, but it will take a good dr to push through their denials. I’m going on Brinsupri probably next month, wish me luck. I have Cigna this year. Hopefully easier than UHC.

I was surprisingly approved in one day this week by Optum RX. Earlier this week and unrelated, Optum notified me my part D monthly premium is rising from $119 to over $200.

@macentee22 My Pulmo said he has had good luck with getting it for his patients, he did not mention Optum RX particularly. He uses Forus which is a firm that specializes in getting drugs approved. My daughter knows them because they were involved in one she was denied so apparently getting pretty popular with doctors, etc.

@rstel7272 Wow your part D is expensive. I just got my part D Annual Notice of Change from Humana and my monthly premium is going from $4.70 to $18.30. 2027 Deductible is $700. Of course, with Brinsupri, I will have to pay the $2400 out of pocket right off the bat in January.
As I am reading through this Annual Notice of Change (complicated) I am having anxiety about whether or not Brinsupri will be covered in 2027. Or must they cover any drug as long as my out of pocket has been paid?

@ursala7 What the plan covers depends on the Part D Formulary for your plan. And if a medication is not on the formulary, it does not count towards your annual out-of-pocket maximum.
I would suggest that you contact your insurer and ask for a link to the 2027 drug formulary, then look up any medications you are taking.

@sueinmn Thanks yes, I need these agents this year for sure. I had no trouble getting the Brinsupri in 2026, but the "annual notice" paperwork makes it clear that there are no guarantees, and that this is my responsibility (to be sure my drugs are covered). So yes, I have sent in the requested survey to my health insurance agent about my drug list and supposedly she will set me up for a review, but they already warned on an email, that they are prioritizing people who are losing their advantage plans this year. They barely got to me in time last year. And of course Thanksgiving comes right in there at the end and eats up days - always a nail biter.