CurrentAvMedPolicy N/A

Metyrosine, Demser, Phenoxybenazmine, Dibenzyline

Prior authorization form and clinical criteria for coverage of metyrosine (Demser) and phenoxybenzamine (Dibenzyline) under AvMed pharmacy benefit. Specifies required documentation, diagnosis, and step therapy/previous trial requirements for approval.

Policy Summary

PayerAvMed

PolicyMetyrosine, Demser, Phenoxybenazmine, Dibenzyline

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed prescriber-signed pharmacy prior authorization/step-edit request via fax to 1-305-671-0200 with required documentation (diagnosis, planned/contraindicated/unsuccessful resection status, prior trial/failure evidence, weight/date when applicable).

SourceLink

POLICY UPDATE CHANGES

No material changes — coverage criteria and requirements remain as previously established.

1Covered Indication (pheochromocytoma only)

3Product-specific step requirements listed

Coverage Summary

Coverage stance: covered_with_criteria for metyrosine (Demser®) and phenoxybenzamine (Dibenzyline®) for the treatment of pheochromocytoma. Scope: Prior authorization form and clinical criteria for coverage of metyrosine (Demser) and phenoxybenzamine (Dibenzyline) under AvMed pharmacy benefit, specifying required documentation, diagnosis, and step therapy/prior trial requirements for approval. Authorization is required via the pharmacy prior authorization/step-edit form and must be submitted with the prescribing physician's signature per the form instructions.

Clinical Criteria for Approval

Covered when ALL of the following are met:

ALL of the following

Member must have a diagnosis of pheochromocytoma
Documentation (lab results, diagnostics, chart notes) must be provided
Provider must submit documentation to confirm resection of the pheochromocytoma is planned or resection of the tumor is contraindicated or has been unsuccessful
Documentation (lab results, diagnostics, chart notes) must be provided
Member must have trial and failure of a selective alpha-blocker e.g., doxazosin, prazosin, terazosin
Verified by chart notes and/or pharmacy paid claims
Product-specific step requirements (ONE of applicable product rules)
- If requesting generic metyrosine (Demser®), trial and failure of generic phenoxybenzamine is required
  Verified by chart notes and/or pharmacy paid claims
- If requesting brand Demser®, trial and failure of generic metyrosine AND phenoxybenzamine is required
  Verified by chart notes and/or pharmacy paid claims
- If requesting brand Dibenzyline®, trial and failure of generic phenoxybenzamine is required
  Verified by chart notes and/or pharmacy paid claims

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Provider Actions / Prior Authorization

Prior Authorization

Prescriber-signed prior authorization form required

A completed pharmacy prior authorization/step-edit request signed by the prescribing physician (hand-signed; preprinted stamps not valid) must be submitted via fax to 1-305-671-0200 with all required member, prescriber, drug, dosing, diagnosis, and documentation fields completed.

Documentation Required

Provide documentation of diagnosis and treatment plan

Submit documentation confirming pheochromocytoma diagnosis and whether resection is planned, contraindicated, or unsuccessful. Include chart notes and/or pharmacy paid claims verifying prior trials and failures of the required selective alpha-blocker(s) and any product-specific step requirements (e.g., trials of phenoxybenzamine or generic metyrosine) as applicable.

Documentation Required

Weight and dosing information when applicable

Provide member weight and the date the weight was obtained on the prior authorization form when applicable.

Denial Risk

Incomplete documentation may delay or deny authorization

Incomplete, incorrect, or illegible information may delay or deny authorization. Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Background & Definitions

This is a pharmacy prior authorization/step-edit request form for metyrosine (Demser®) and phenoxybenzamine (Dibenzyline®). It defines the clinical prerequisites and documentation required for authorization in members with pheochromocytoma, including completion of member, prescriber, drug, dosing, diagnosis, and documentation fields, and submission via fax to 1-305-671-0200 with the prescribing physician's hand-signed signature.

Trial and failure: Verified by chart notes and/or pharmacy paid claims showing prior use and inadequate response, intolerance, or contraindication to the specified agent(s).