Health Net
Ravicti (glycerol phenylbutyrate)
Drugs that Alter Metabolism : Drugs that Alter Metabolism
  • Step Therapy: Urea Cycle Disorder:
    ST Single Generic

  • Limited Access.
  • Prior Authorization: Urea Cycle Disorder:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 1 plan year
    Reauthorization Required: Yes

  • Urea Cycle Disorder:
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Physician experienced in treating metabolic disorder
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

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