sodium phenylbutyrate — Medical Mutual

Initial criteria

• Diagnosis confirmed by genetic or enzymatic testing according to the prescriber; AND
• Patient is following a protein-restricted diet; AND
• Drug is prescribed by or in consultation with a provider specializing in metabolic disorders, a genetic specialist, or a physician experienced in the management of urea cycle disorders; AND
• If the request is for Buphenyl or Olpruva the patient meets one of the following: i) Patient has tried generic sodium phenylbutyrate; OR ii) Patient has tried Pheburane; OR
• If the request is for Ravicti the patient meets one of the following: i) Patient has tried generic sodium phenylbutyrate; OR ii) Patient has tried Pheburane; OR iii) Patient is on a sodium-restricted diet OR a high sodium diet is contraindicated according to the prescriber; OR iv) Patient is unable to eat soft food and does NOT have a feeding tube (e.g. young infant).

Reauthorization criteria

• Response to therapy is required for continuation of therapy unless otherwise noted.

Approval duration

1 year initial, 1 year reauth