Urea Cycle Disorders
PDL Reference Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 75987005006 | RAVICTI | glycerol phenylbutyrate | LIQUID | 1.1 gram/mL | N | Y | |
| 71770020010 | PHEBURANE | sodium phenylbutyrate | GRANULES | 483 mg/gram | Y | Y | |
| 72542000201 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 2 gram | N | Y | |
| 72542020002 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 2 gram | N | Y | |
| 72542020009 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 2 gram | N | Y | |
| 72542000301 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 3 gram | N | Y | |
| 72542030002 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 3 gram | N | Y | |
| 72542030009 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 3 gram | N | Y | |
| 72542040002 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 4 gram | N | Y | |
| 72542040018 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 4 gram | N | Y | |
| 72542050002 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 5 gram | N | Y | |
| 72542050018 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 5 gram | N | Y | |
| 72542060002 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 6 gram | N | Y | |
| 72542060018 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 6 gram | N | Y | |
| 72542066702 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 6.67 gram | N | Y | |
| 72542066718 | OLPRUVA | sodium phenylbutyrate | PELET PACK | 6.67 gram | N | Y | |
| 75987007009 | BUPHENYL | sodium phenylbutyrate | POWDER | 0.94 gram/gram | Y | Y | |
| 42794008614 | SODIUM PHENYLBUTYRATE | sodium phenylbutyrate | POWDER | 0.94 gram/gram | Y | Y | |
| 49884000604 | SODIUM PHENYLBUTYRATE | sodium phenylbutyrate | POWDER | 0.94 gram/gram | Y | Y | |
| 75987006008 | BUPHENYL | sodium phenylbutyrate | TABLET | 500 mg | Y | Y | |
| 49884017004 | SODIUM PHENYLBUTYRATE | sodium phenylbutyrate | TABLET | 500 mg | Y | Y | |
| 68462085320 | SODIUM PHENYLBUTYRATE | sodium phenylbutyrate | TABLET | 500 mg | Y | Y |