Metyrosine — Medical Mutual

Initial criteria

• The patient has tried a selective alpha blocker (e.g., doxazosin, terazosin or prazosin); AND
• The patient has tried phenoxybenzamine (brand or generic); AND
• Metyrosine is prescribed by, or in consultation with, an endocrinologist or a prescriber who specializes in the management of pheochromocytoma; AND
• The patient has a surgical resection planned, has a contraindication to surgery, or has chronic malignant pheochromocytoma; AND
• If the request is for brand Demser, the patient has tried or experienced intolerance to generic metyrosine

Reauthorization criteria

• Patient is currently receiving metyrosine; AND
• Metyrosine is prescribed by, or in consultation with, an endocrinologist or a prescriber who specializes in the management of pheochromocytoma; AND
• The member’s condition has improved or stabilized while on therapy

Approval duration

initial 3 months; reauth 1 year