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

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Limited coverage criteria – glycerol phenylbutyrate

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)