Cuvrior (trientine tetrahydrochloride tablets – Orphalan) — Cigna

Wilson’s disease

Initial criteria

Diagnosis of Wilson’s disease is confirmed by ONE of the following (i or ii): i. Genetic testing results confirming biallelic pathogenic ATP7B mutations (in either symptomatic or asymptomatic individuals); OR ii. Confirmation of at least TWO of the following (TWO of a, b, c, or d): a) Presence of Kayser-Fleischer rings; OR b) Serum ceruloplasmin level < 20 mg/dL; OR c) Liver biopsy findings consistent with Wilson’s disease; OR d) 24-hour urinary copper > 40 mcg/24 hours
Patient meets ONE of the following (i, ii, iii, iv, v or vi): i. According to the prescriber, patient has tried one penicillamine product and is intolerant to penicillamine therapy; OR ii. According to the prescriber, patient has clinical features indicating the potential for intolerance to penicillamine therapy; OR iii. According to the prescriber, patient has a contraindication to penicillamine therapy; OR iv. Patient has neurologic manifestations of Wilson’s disease; OR v. Patient is pregnant; OR vi. Patient has been started on therapy with trientine (Cuvrior or Syprine, generic)
The medication is prescribed by or in consultation with a gastroenterologist, hepatologist, or liver transplant physician

1 year