Thiola EC — Cigna
severe homozygous cystinuria for the prevention of cystine kidney stone formation in adults and pediatric patients ≥ 20 kg who are not responsive to high fluid intake, alkali, and diet modification alone
Preferred products
- generic tiopronin delayed-release tablets
- generic tiopronin tablets
- Venxxiva tablets
Initial criteria
- Patient meets the standard Metabolic Disorders – Tiopronin Products Prior Authorization Policy criteria; AND
- Patient meets ONE of the following (i or ii):
- i. Patient has tried ONE of generic tiopronin delayed-release tablets or Venxxiva tablets [documentation required]; OR
- ii. Patient has tried generic tiopronin tablets [documentation required]; AND
- Patient cannot continue to use generic tiopronin or Venxxiva due to a formulation difference in the inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Approval duration
as listed in Metabolic Disorders – Tiopronin Products Prior Authorization Policy