Pheburane (sodium phenylbutyrate) — Highmark

Preferred products

• Generic sodium phenylbutyrate

Initial criteria

• The member is using Buphenyl or Pheburane for chronic management of urea cycle disorders (ICD-10: E72.20)
• The member is using Buphenyl or Pheburane involving deficiencies of carbamylphosphate synthetase (CPS), argininosuccinic acid synthetase (AS), or ornithine transcarbamylase (OTC)
• The member is using Buphenyl or Pheburane as adjunctive therapy to dietary protein restriction
• If the request is for brand Buphenyl, the member has experienced therapeutic failure, intolerance, or contraindication to generic sodium phenylbutyrate
• If the request is for brand Pheburane, the member has experienced therapeutic failure, intolerance, or contraindication to plan-preferred generic sodium phenylbutyrate

Reauthorization criteria

• The prescriber attests that the member has experienced positive clinical response to therapy (e.g., reduction in blood ammonia levels)
• The member is continuing use of requested drug with standard of care (e.g., dietary protein restriction and/or amino acid supplementation)

Approval duration

12 months