UnitedHealthcare |
Ravicti (glycerol phenylbutyrate) |
Drugs that Alter Metabolism : Drugs that Alter Metabolism |
- Urea Cycle Disorder:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior Authorization: Urea Cycle Disorder:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: Urea Cycle Disorder:
ST Single Generic
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