trientine hydrochloride 500 mg capsules — Highmark

Preferred products

• trientine hydrochloride 250 mg capsules

Initial criteria

• Member has a diagnosis of Wilson’s disease
• Member has experienced therapeutic failure or intolerance to plan-preferred generic trientine hydrochloride 250 mg capsules

Reauthorization criteria

• Member has documentation of positive response to therapy
• Member continues to have a diagnosis of Wilson’s disease

Approval duration

12 months