Phenoxybenzamine — Medical Mutual

Initial criteria

• The agent 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 malignant pheochromocytoma; AND
• The patient is using the requested medication to control sweating and hypertension associated with pheochromocytoma

Reauthorization criteria

• Patient is currently receiving phenoxybenzamine; AND
• Phenoxybenzamine 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