Thiola — Medical Mutual

Initial criteria

• Patient weighs ≥ 20 kg
• Diagnosis of cystinuria has been confirmed based on laboratory testing (e.g., urinary cystine crystals present on microscopy, quantitative urine cystine assay)
• According to the prescriber, the patient has had an inadequate response to high fluid intake, dietary modification, and urinary alkalization
• The medication is prescribed by or in consultation with a nephrologist, urologist, or physician who specializes in the treatment of cystinuria

Reauthorization criteria

• Response to therapy is required for continuation of therapy

Approval duration

initial 6 months; reauth 6 months