Limited coverage criteria – glycerol phenylbutyrate

Last updated on May 16, 2025

 

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Generic name

glycerol phenylbutyrate

Strength & form

1.1 g/mL oral liquid

Special Authority criteria

Approval period

For the chronic management of urea cycle disorders (UCD)

1 year

Practitioner exemptions

  • A Collaborative Prescribing Agreement (CPA) 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

  • None

Special Authority request form(s)

  • Special Authority request forms are not required. Coverage is via CPA only