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The Policy VaultThe Policy Vault

Ravicti — Cigna

Chronic management of patients with urea cycle disorders (UCDs) that cannot be managed by dietary protein restriction and/or amino acid supplementation alone

Preferred products

  • generic sodium phenylbutyrate
  • Pheburane

Initial criteria

  • Patient meets the standard Metabolic Disorders – Phenylbutyrate Products Prior Authorization Policy criteria; AND
  • Patient meets ONE of the following (i, ii, iii, or iv):
  • i. Patient has tried generic sodium phenylbutyrate; OR
  • ii. Patient has tried Pheburane; OR
  • iii. Patient is on a sodium-restricted diet OR, according to the prescriber, a high sodium diet is contraindicated [documentation required]; OR
  • iv. Patient is unable to eat soft food and does NOT have a feeding tube (e.g. young infant).

Approval duration

1 year