Dibenzyline — Medica

Preferred products

• phenoxybenzamine (generic)

Initial criteria

• Patient has diagnosis of pheochromocytoma
• If brand Dibenzyline is requested, patient has tried generic phenoxybenzamine AND cannot continue to use generic phenoxybenzamine due to a formulation difference in inactive ingredients that would result in a significant allergy or a serious adverse reaction [documentation required]
• Medication is prescribed by or in consultation with an endocrinologist or a physician who specializes in the management of pheochromocytoma

Approval duration

1 year