Depen — Medical Mutual

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 or ii):
• i. Generic penicillamine capsules or tablets are requested; OR
• ii. If brand Depen is prescribed, patient has tried generic penicillamine tablets AND cannot take generic penicillamine tablets due to a formulation difference in the inactive ingredient(s) [e.g., difference in dyes, fillers, preservatives] between the Brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction.

Reauthorization criteria

• Response to therapy is required for continuation of therapy.

Approval duration

1 year