Oral Penicillamine Products (Revised)

REQUIREMENTS: - Immediately: Billing and clinical teams must implement prior authorization requirement for all oral penicillamine products (Cuprimine, Depen Titratabs, penicillamine capsule, penicillamine tablet in 250mg formulations) for Medicare Advantage members before submitting claims. - Update billing system to flag all penicillamine prescriptions for prior auth review. Ensure system requires documentation of: * For Wilson's Disease: Confirmation of diagnosis via Kayser-Fleischer rings + low ceruloplasmin + elevated 24-hour urinary copper OR molecular genetic confirmation OR liver biopsy confirmation, PLUS prior treatment with or intolerance to generic penicillamine tablet * For Cystinuria: Documented cystinuria diagnosis, concurrent use of high fluid intake (≥2.5L daily), potassium citrate for urine pH elevation, dietary modifications (limited sodium/protein), failure of preventative measures alone, AND prior treatment with or intolerance to generic penicillamine tablet * For Rheumatoid Arthritis: RA diagnosis, prior treatment with or intolerance to ONE conventional agent (hydroxychloroquine, leflunomide, methotrexate, or sulfasalazine), AND prior treatment with or intolerance to generic penicillamine tablet - Create provider education materials explaining these three distinct clinical pathways and required documentation for each indication. - Do NOT submit claims without prior authorization approval. Claims submitted without meeting these criteria or without prior auth will be denied. - For any patient with penicillamine-induced agranulocytosis or aplastic anemia history, or rheumatoid arthritis patients with renal insufficiency: Do not request authorization (contraindicated). - Verify approval duration is plan year (initial and renewal approval through plan year end).