Ravicti (glycerol phenylbutyrate) — Point32Health
chronic management of patients with urea cycle disorders (UCDs) who cannot be managed by dietary protein restriction and/or amino acid supplementation alone
Preferred products
- generic Buphenyl
Initial criteria
- Documented diagnosis of a urea cycle disorder confirmed by enzymatic, biochemical, or genetic testing
- Documentation the patient’s condition cannot be managed by dietary protein restriction and/or amino acid supplementation alone
- Documentation the requested medication will be used as an adjunct to a protein-restricted diet
- Documentation of ONE of the following: (a) Inadequate response to generic Buphenyl at optimized doses OR (b) Inability to tolerate a therapeutic dose of generic Buphenyl due to palatability