Pheburane — CareFirst (Caremark)
chronic management of urea cycle disorders (UCDs) involving deficiencies of carbamylphosphate synthetase (CPS), ornithine transcarbamylase (OTC), argininosuccinic acid synthetase (AS), or arginase deficiency
Initial criteria
- The diagnosis is confirmed by enzymatic, biochemical, or genetic testing.
- The member has elevated plasma ammonia levels at baseline.
- If the request is for Olpruva, patient weighs ≥ 20 kg.
- If the request is for Olpruva, patient has a body surface area (BSA) ≥ 1.2 m2.
Reauthorization criteria
- Member is experiencing benefit from therapy as evidenced by a reduction in plasma ammonia levels from baseline.
Approval duration
12 months