Limited Coverage Drugs – Glycerol Phenylbutyrate

Generic Name

glycerol phenylbutyrate

Strength

1.1 g/mL

Form

oral liquid

Special Authority Criteria

Approval Period

For the chronic management of urea cycle disorders (UCD).

1 year

Practitioner Exemptions

  • A Collaborative Prescribing Agreement is available to a limited number of practitioners, specializing in the chronic management of UCD, who are working in a designated metabolic disease clinic.

Special Notes

  • No special notes.

Special Authority Request Form(s)

  • Special Authority request forms are not required.