Buphenyl — CareFirst (Caremark)

Initial criteria

• Diagnosis is confirmed by enzymatic, biochemical, or genetic testing
• Member has elevated plasma ammonia levels at baseline
• If the request is for Olpruva, patient weighs 20 kg or greater
• If the request is for Olpruva, patient has a body surface area (BSA) of 1.2 m2 or greater

Reauthorization criteria

• Member is experiencing benefit from therapy as evidenced by a reduction in plasma ammonia levels from baseline

Approval duration

12 months