Pharmacy Prior Authorization Criteria

Dibenzyline (phenoxybenzamine)

Indications for Prior Authorization

Dibenzyline (phenoxybenzamine)

• For diagnosis of Pheochromocytoma
  Indicated in the treatment of pheochromocytoma to control episodes of hypertension and swelling.

Criteria

Brand Dibenzyline, generic phenoxybenzamine

Prior Authorization

Length of Approval: 1 Time(s) [A]
For diagnosis of Pheochromocytoma

• Diagnosis of pheochromocytoma confirmed by one of the following biochemical testing: [2]
• plasma free metanephrines
• urinary fractioned metanephrines
AND
• Medication is being used for preoperative preparation [A,1]
AND
• Trial and failure, contraindication, or intolerance to one of the following:
• doxazosin
• terazosin
• prazosin
AND
• Treatment will also include a high-sodium diet and fluid intake [B]
AND
• Prescribed by or in consultation with one of the following:
• Endocrinologist
• Endocrine surgeon

P & T Revisions

2024-02-22, 2023-03-01, 2022-10-26, 2022-02-10

References

1. Farrugia F, Martikos G, Tzanetis P, et al. Pheochromocytoma, diagnosis and treatment: Review of the literature. Endocrine Regulations. 2017;51(3):168-181.
2. Lenders JWM, Duh Q-Y, Eisenhofer G, et al. Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2014;99(6):1915-1942.
3. Phenoxybenzamine Prescribing Information. Amneal Pharmaceuticals LLC. Bridgewater, NJ. July 2023.

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End Notes

1. Phenoxybenzamine is most commonly used for preoperative control of blood pressure. Its only current clinical use is in preparing patients with pheochromocytoma for surgery. [1]
2. Retrospective studies report that initiation of high-sodium diet a few days after the start of alpha-adrenergic receptor blockade reverses blood volume contraction, prevents orthostatic hypotension before surgery, and reduces the risk of significant hypotension after surgery. [2]

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Revision History

• 2024-02-22: 2024 Annual Review. Updated References.
• 2023-03-01: 2023 Annual Review - no changes
• 2022-10-26: Attached EHB formulary
• 2022-02-10: New Program

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