Limited coverage criteria – trientine

Last updated on March 24, 2025

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Generic name		trientine
Strength & form		250 mg capsule

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

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 request form(s)

Log in to eForms
HLTH 5328 – General Special Authority request (PDF, 656KB)

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