CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dibenzyline (phenoxybenzamine) prior authorization

Defines prior authorization and quantity limit requirements for dibenzyline (phenoxybenzamine) when prescribed for pheochromocytoma or paraganglioma; applies to members whose pharmacy benefits are managed under this payer's CVS Caremark criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDibenzyline (phenoxybenzamine) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis plus trial, intolerance, or contraindication to an alpha-1 selective adrenergic blocker.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsDOA

360 caps/25dQTY limit (30-day)

1,080 caps/75dQTY limit (90-day)

pheochromocytomaApproved indication

Coverage Criteria

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Primary indication: Patient has diagnosis of pheochromocytoma or paraganglioma and dibenzyline is prescribed to control episodes of hypertension and sweating.

FDA-approved for pheochromocytoma; paraganglioma listed as compendial use

Prior trial: Patient has experienced an inadequate treatment response to an alpha-1 selective adrenergic receptor blocker (e.g., doxazosin, prazosin, terazosin).

Step therapy: trial required unless intolerance/contraindication documented

Intolerance: Patient has experienced an intolerance to an alpha-1 selective adrenergic receptor blocker (e.g., doxazosin, prazosin, terazosin).

Intolerance acceptable alternative to prior trial

Contraindication: Patient has a contraindication that would prohibit a trial of an alpha-1 selective adrenergic receptor blocker (e.g., doxazosin, prazosin, terazosin).

Contraindication acceptable alternative to prior trial

Requests lacking documentation of the diagnosis or without evidence that the patient has had an inadequate treatment response, intolerance, or a contraindication to an alpha‑1 selective adrenergic receptor blocker (for example, doxazosin, prazosin, terazosin) are not supported by these criteria and may be denied.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for dibenzyline (phenoxybenzamine) as an initial prior authorization with a quantity limit. Approvals are consistent with the clinical criteria below.

Initial prior authorization required
Quantity limits: 360 capsules per 25 days (30-day fill period) or 1,080 capsules per 75 days (90-day fill period); duration of approval: 12 months

Step Therapy

Step Therapy Requirement

A trial of an alpha-1 selective adrenergic receptor blocker (e.g., doxazosin, prazosin, terazosin) is required prior to approval unless there is documented intolerance or a contraindication to such an agent.

Step therapy: Trial of an alpha-1 selective adrenergic receptor blocker required (examples: doxazosin, prazosin, terazosin)
Exception: documented intolerance, contraindication, or inadequate response to an alpha-1 blocker

Documentation Required

Required Clinical Documentation

Documentation must support the diagnosis of pheochromocytoma or paraganglioma and justify use of dibenzyline, including prior treatment history and reason for escalation to phenoxybenzamine.

Diagnosis: clinical documentation supporting pheochromocytoma or paraganglioma
Treatment history: documentation of prior trial and inadequate response to an alpha-1 selective adrenergic receptor blocker, OR documented intolerance OR documented contraindication to an alpha-1 blocker
Clinical rationale: indication for dibenzyline to control hypertension and sweating; note if concomitant beta-blocker is used for excessive tachycardia

Denial Risk

Missing Failure/Intolerance/Contraindication to Alpha-1 Blocker

Requests lacking documentation of prior intolerance, contraindication, or inadequate response to an alpha-1 selective adrenergic blocker (when step therapy is otherwise required) are at risk for denial.

If no documentation of prior trial and inadequate response to an alpha-1 blocker, or no documented intolerance/contraindication, the request may be denied

Definitions

Dibenzyline (phenoxybenzamine)

Drug class and nameDibenzyline (phenoxybenzamine), an irreversible nonselective alpha-adrenergic antagonist

FDA‑approved indicationTreatment of pheochromocytoma to control episodes of hypertension and sweating

Adjunct therapy noteIf tachycardia is excessive, concomitant beta‑blocking agents may be necessary

Compendial useListed for use in paragangliomas (compendial)

Background

Phenoxybenzamine (Dibenzyline) is an alpha‑adrenergic blocker used to control hypertension and sweating in patients with pheochromocytoma; it may also be used for paraganglioma per compendial sources. Clinical use for these tumors is intended to manage paroxysmal symptoms prior to definitive therapy, and consideration of beta‑blockade may be necessary if tachycardia develops.