Drug - NutreStore™ (L-glutamine powder for oral solution) Emmaus Medical
Description - 5 gram powder in a packet, prescription product
Dose - 30 gm daily in divided doses (5 gm taken 6 times each day)
Each 5 gram dose should be reconstituted in 8-oz of water
Supplied in packets containing 5 gm
It is indicated only for the treatment of Short Bowel Syndrome (SBS) in patients receiving specialized nutritional support when used in conjunction with a recombinant human growth hormone (Zorbitve).
The PA criteria is limited to it FDA approved indication:
MHCP Provider Call Center 651-431-2700 or 800-366-5411