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Depen — Medica

Cystinuria

Preferred products

  • penicillamine tablets (generic)

Initial criteria

  • According to the prescriber, patient has tried increased fluid intake; restriction of sodium and protein; and urinary alkalinization; AND
  • Patient meets ONE of the following: (i) generic penicillamine tablets are requested; OR (ii) if brand Depen is being requested, patient has tried generic penicillamine tablets AND cannot take generic penicillamine tablets due to a formulation difference in the inactive ingredient(s) (e.g., dyes, fillers, preservatives) which, per the prescriber, would result in a significant allergy or serious adverse reaction.

Approval duration

1 year