Medicare AdvantagePrior AuthMedium impact
Pheburane® and Olpruva™ (sodium phenylbutyrate) (Revised)
Humana·Pediatrics, Internal Medicine, Genetics·Medicare Advantage
Effective date
Dec 28, 2022
We identified it
Jun 25, 2026
Summary
This is a revised Medicare Advantage pharmacy prior authorization policy for Pheburane® and Olpruva™ (sodium phenylbutyrate) products used to treat urea cycle disorders. The policy requires prior authorization and mandates that members must have tried or be unable to use generic sodium phenylbutyrate before these brand products are covered. Coverage is limited to plan year duration for both initial and renewal periods.
Action Required
Before February 25, 2026 (revision date): Billing team must ensure prior authorization protocols are in place for Pheburane® oral granules and Olpruva™ oral pellets in the billing system. When processing claims, verify that: (1) member has documented diagnosis of urea cycle disorder (UCD), (2) medication is being used with low protein diet as adjunctive therapy, and (3) member has tried or cannot use generic sodium phenylbutyrate product. Contact Humana for prior authorization using www.humana.com/PAL before dispensing. Update pharmacy system to flag these medications as requiring PA and to deny claims if generic sodium phenylbutyrate has not been documented as tried or contraindicated. Note that initial and renewal approvals are limited to plan year duration. Failure to obtain prior authorization will result in claim denials.