Dibenzyline (phenoxybenzamine capsules) — Cigna

Pheochromocytoma

Preferred products

For Dibenzyline (phenoxybenzamine): Approve for 1 year if BOTH of the following are met (A and B):
A) If brand Dibenzyline is requested, patient meets BOTH of the following (i and ii):
i. Patient has tried generic phenoxybenzamine; AND
ii. Patient cannot continue to use generic phenoxybenzamine due to a formulation difference in the inactive ingredient(s) [e.g., difference in dyes, fillers, preservatives] between the brand and the bioequivalent generic product which, according to the prescriber, would result in a significant allergy or a serious adverse reaction [documentation required]; AND
B) The medication is prescribed by or in consultation with an endocrinologist or a physician who specializes in the management of pheochromocytoma.
For Demser (metyrosine): Approve for 1 year if ONE of the following (A or B) is met:
A) Initial Therapy: Approve for 1 year if ALL of the following (i, ii, and iii) are met:
i. Patient has tried a selective alpha blocker (e.g., doxazosin, terazosin, or prazosin); AND
ii. Patient has tried phenoxybenzamine (brand or generic); AND
iii. The medication is prescribed by, or in consultation with, an endocrinologist or a physician who specializes in the management of pheochromocytoma; OR
B) Patient is currently receiving metyrosine and it is prescribed by or in consultation with an endocrinologist or a physician who specializes in the management of pheochromocytoma.

Patient is currently receiving metyrosine and it is prescribed by or in consultation with an endocrinologist or a physician who specializes in the management of pheochromocytoma.

1 year