CurrentColorado Rocky Mountain Health PlansPolicy N/A

Cuvrior (trientine tetrahydrochloride) prior authorization

Defines prior authorization requirements for Cuvrior (trientine tetrahydrochloride) for members covered by the payer; affects providers seeking coverage for adult patients with Wilson's disease.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCuvrior (trientine tetrahydrochloride) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization by documenting diagnosis of Wilson's disease, de-coppered status (NCC 25–150 mcg/L), tolerance to penicillamine, and discontinuation of penicillamine before starting Cuvrior.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

NCC 25–150NCC requirement

Adultsindicated population

2026 P 1401-5program id

Coverage Criteria for Cuvrior (trientine tetrahydrochloride)

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inv-01: Initial Authorization

Covered when ALL of the following are met

Initial Authorization: Diagnosis of Wilson's disease; patient is de-coppered (serum non-ceruloplasmin copper [NCC] level ≥ 25 and ≤ 150 mcg/L); patient is tolerant to penicillamine; patient will discontinue penicillamine before starting therapy with Cuvrior.

Authorization will be issued for 12 months.

Policy history notes that Cuvrior has been the subject of program updates since introduction, including a 2/2024 update that specifically added a footnote stating that Cuvrior is typically excluded from coverage. Subsequent reviews through 2/2026 made no changes to coverage criteria but retained the historical note about the drug's usual exclusion status.

These historical notes reflect prior program-level decisions and are retained for context; current coverage is governed by the criteria in this document rather than the prior exclusion footnote when those criteria are met.

Initial Therapy Requirements

inv-11: Initial Therapy

Initial coverage criteria

Initial Therapy: Diagnosis of Wilson's disease; patient de-coppered (serum non-ceruloplasmin copper [NCC] level ≥ 25 and ≤ 150 mcg/L); patient is tolerant to penicillamine; penicillamine will be discontinued prior to starting Cuvrior.

Authorization will be issued for 12 months.

Continuation / Reauthorization Criteria

inv-12: Continuation Therapy / Reauthorization

Reauthorization rules

Continuation Therapy / Reauthorization: Documentation of positive clinical response to Cuvrior therapy is required for continuation of therapy.

Authorization will be issued for 12 months.

Provider Actions, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required for initiation of Cuvrior. Initial approval is for 12 months and requires documentation that the patient has Wilson's disease and is in the de-coppered NCC range specified below.

Initial authorization duration: 12 months
Required diagnosis: Wilson's disease
Required NCC range for approval: serum non-ceruloplasmin copper (NCC) ≥ 25 and ≤ 150 mcg/L

Step Therapy

Penicillamine Tolerance and Discontinuation

Step-therapy / tolerance requirement: the patient must have tolerated penicillamine and penicillamine must be discontinued prior to initiating Cuvrior.

Patient must be tolerant to penicillamine
Penicillamine must be discontinued before starting Cuvrior

Documentation Required

Required Documentation

Provider must document the clinical and laboratory information below when requesting authorization. Include supporting records in the request to avoid processing delays.

Diagnosis: documentation confirming Wilson's disease
Serum NCC result demonstrating a de-coppered level (≥ 25 and ≤ 150 mcg/L) — include date and lab reference range
Documentation of penicillamine tolerance and confirmation that penicillamine will be discontinued prior to Cuvrior initiation
For reauthorization: documentation of positive clinical response to Cuvrior therapy
Any additional supporting labs or clinical notes referenced in the request

Denial Risk

Triggers for Denial

Authorization may be denied if required criteria or documentation are missing or do not meet the policy specifications.

No documented diagnosis of Wilson's disease
Missing or out-of-range serum NCC (not ≥ 25 and ≤ 150 mcg/L)
No documentation of penicillamine tolerance or failure to document discontinuation of penicillamine prior to Cuvrior
Missing supporting laboratory results or clinical notes required for initial authorization or reauthorization

Step	Requirement
1	Patient must be tolerant to penicillamine and penicillamine must be discontinued before initiating Cuvrior.

Background

Cuvrior (trientine tetrahydrochloride) is a copper chelator indicated for the treatment of adult patients with Wilson's disease. The policy defines the treated population as adults who are de-coppered and tolerant to penicillamine, and uses serum non-ceruloplasmin copper (NCC) to operationalize the de-coppered state.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCuvrior (trientine tetrahydrochloride) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Cuvrior (trientine tetrahydrochloride) prior authorization

Coverage Criteria for Cuvrior (trientine tetrahydrochloride)

Initial Therapy Requirements

Continuation / Reauthorization Criteria

Laboratory / Diagnostic Thresholds

Provider Actions, Documentation, and Denial Triggers

Step-Therapy / Treatment Preconditions

Definitions

Background