Limited coverage drugs – trientine

Generic name

trientine

Strength

250 mg

Form

capsules

Special Authority criteria

Approval period

Initial:

  • Diagnosis of Wilson’s disease

AND

  • Initial request for pediatric and adult patients is by a specialist experienced in the management of Wilson’s disease

AND

  • Demonstrated intolerance to d-penicillamine. Details of nature and severity of intolerance(s) experienced must be provided.

1 year

Renewal:

  • Provide details of ongoing benefit and tolerability.

1 year

Practitioner exemptions

  • None

Special notes

  • Renewal requests for pediatric patients must be submitted by a specialist experienced in the management of Wilson’s disease.

Special Authority requests