Pheburane (sodium phenylbutyrate oral pellets – Medunik) — Cigna

Initial criteria

• Diagnosis confirmed by ONE of the following (i or ii):
• i. Genetic or enzymatic testing confirmed a urea cycle disorder; OR
• ii. Patient has hyperammonemia diagnosed with an ammonia level above the upper limit of the normal reference range for the reporting laboratory.
• Medication is prescribed in conjunction with a protein-restricted diet; AND
• Patient will not be receiving concurrent therapy with another phenylbutyrate product; AND
• Medication is prescribed by or in consultation with a metabolic disease specialist (or specialist who focuses in the treatment of metabolic diseases).

Approval duration

1 year if genetic/enzymatic testing confirmed; 3 months if hyperammonemia diagnosed by ammonia level