Cuvrior (trientine tetrahydrochloride)

Self-Administration – Oral

Diagnosis considered for coverage:
  • Wilson's Disease: Indicated for the treatment of adult patients with stable Wilson's disease who are de-coppered and tolerant to penicillamine.

Coverage Criteria:

For diagnosis of Wilson's disease:

  • Dose does not exceed 3,000 mg per day, AND

  • Diagnosis of Wilson's disease (i.e., hepatolenticular degeneration), AND

  • Prescribed by or in consultation with one of the following:

    • Gastroenterologist

    • Hepatologist, AND

  • Documentation of one of the following:

    • Presence of Kayser-Fleisher rings

    • Serum ceruloplasmin (CPN) less than 20 mg/dL

    • 24-hour urinary copper excretion greater than 100 mcg

    • Liver biopsy with copper dry weight greater than 250 mcg/g

    • ATP7B mutation via genetic testing, AND

  • Trial and failure, or intolerance to Depen (penicillamine) tablets

Reauthorization Criteria:

For diagnosis of Wilson's disease:

  • Documentation of a positive clinical response to therapy

Coverage Duration:
  • Initial: 12 months

  • Reauthorization: 12 months

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Policy Updates:

11/14/2023 – New policy approved by P&T.

References:
  1. Pearle MS, Goldfarb DS, Assimos DG, et al. Medical management of kidney stones: AUA guideline. J Urol. 2014 Aug;192(2):316-24.

  2. Fattah H, Hambaroush Y, Goldfarb DS. Cystine nephrolithiasis. Transl Androl Urol. 2014 Sep 1;3(3):228-233. doi: 10.3978/j.issn.2223-4683.2014.07.04.

  3. European Association for Study of Liver. EASL Clinical Practice Guidelines: Wilson's disease. J Hepatol. 2012;56(3):671-685.

  4. Cuvrior Prescribing Information. Orphalan SA. Chicago, IL. May 2022.

Last review date: December 1, 2023

Rite Aid Pharmacy Patients: All Rite Aid pharmacies nationwide are closing! Please be on the lookout for information from Rite Aid pharmacies about their bankruptcy and store closures. Call your Rite Aid pharmacy for questions about your prescriptions and new pharmacy options. WHA is here to help as well. Contact Us via Phone