Ravicti — CareFirst (Caremark)

Initial criteria

• The diagnosis is confirmed by enzymatic, biochemical, or genetic testing.
• The member has elevated plasma ammonia levels at baseline.
• Medication must be prescribed by or in consultation with a physician who specializes in the treatment of enzyme or metabolic disorders.

Reauthorization criteria

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

Approval duration

12 months