| Anthem Blue Cross (HMO, PPO, EPO) |
| sodium phenylbutyrate (sodium phenylbutyrate) |
| Drugs that Alter Metabolism : Drugs that Alter Metabolism |
- Quantity Limit: 40 tablets per 1 day(s).
- Urea Cycle Disorder:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- PA Applies
- Prior Authorization: Urea Cycle Disorder:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
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