metyrosine — Highmark
pheochromocytoma
Preferred products
- doxazosin
- prazosin
- terazosin
- generic metyrosine
Initial criteria
- Diagnosis of pheochromocytoma (ICD-10: C74.10) defined by one of the following: elevated metanephrines in plasma or urine OR tumor evidence from CT scan or MRI
- Member meets one of the following: planned resection surgery OR resection surgery is contraindicated OR malignant pheochromocytoma
- Member has experienced therapeutic failure, contraindication, or intolerance to one of the following: doxazosin OR prazosin OR terazosin
- If request is for brand Demser, member has experienced therapeutic failure or intolerance to generic metyrosine
Reauthorization criteria
- Member meets one of the following: incomplete response to tumor resection OR resection surgery is contraindicated OR malignant pheochromocytoma
- Member has experienced a positive clinical response to therapy (e.g., symptom improvement, reduction in hypertensive episodes)
Approval duration
12 months