metyrosine — CareFirst (Caremark)

Initial criteria

• Member has experienced an inadequate treatment response, intolerance, or has a contraindication to an alpha-adrenergic antagonist (e.g., terazosin, doxazosin, prazosin, phenoxybenzamine)
• AND one of the following:
• Requested agent will be used for preoperative preparation for surgery
• OR requested agent will be used for management when surgery is contraindicated
• OR requested agent will be used for chronic treatment for malignant pheochromocytoma

Reauthorization criteria

• Member has improvement in symptoms (e.g., blood pressure, heart rate, headaches, sweating, anxiety)
• AND no unacceptable toxicity while on the current regimen

Approval duration

12 months