Pheburane (sodium phenylbutyrate) — United Healthcare

Initial criteria

• Diagnosis of urea cycle disorders (UCDs)
• Will be used concomitantly with dietary protein restriction and, in some cases, dietary supplements (e.g., essential amino acids, arginine, citrulline, protein-free calorie supplements)

Reauthorization criteria

• Documentation of positive clinical response to therapy
• Patient is actively on dietary protein restriction and, in some cases, dietary supplements (e.g., essential amino acids, arginine, citrulline, protein-free calorie supplements)

Approval duration

12 months