sodium phenylbutyrate (generic) — CareFirst (Caremark)
Urea cycle disorders (UCDs) involving deficiencies of carbamylphosphate synthetase (CPS), ornithine transcarbamylase (OTC), or argininosuccinic acid synthetase (AS)
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