Dibenzyline (phenoxybenzamine) — Highmark
pheochromocytoma
Preferred products
- doxazosin
- prazosin
- terazosin
Initial criteria
- age ≥ 18 years
- Diagnosis of pheochromocytoma (ICD-10: C74.10) defined by ONE of the following:
- 1. Elevated metanephrines in plasma or urine as defined by:
- a. Plasma fractionated metanephrines (Normetanephrines > 0.6 nmol/L OR Metanephrine > 0.3 nmol/L)
- b. 24-hour urine fractionated metanephrines and catecholamines (Normetanephrine > 900 mcg/24 hours OR Metanephrine > 400 mcg/24 hours OR Norepinephrine > 170 mcg/24 hours OR Epinephrine > 35 mcg/24 hours OR Dopamine > 700 mcg/24 hours)
- OR 2. Tumor evidence from CT scan or MRI
- Member is experiencing excessive sweating AND hypertension
- Therapeutic failure to, intolerance to, or contraindication to ONE of the following plan-preferred products: doxazosin, prazosin, terazosin
Reauthorization criteria
- Member experienced an incomplete response to tumor resection OR member’s tumor is unresectable
Approval duration
12 months