Pharmacy Prior Authorization Criteria

Demser (metyrosine)

Indications for Prior Authorization

Demser (metyrosine)

• For diagnosis of Pheochromocytoma
  Indicated for the treatment of patients with pheochromocytoma for preoperative preparation of patients for surgery, management of patients when surgery is contraindicated, and chronic treatment of patients with malignant pheochromocytoma. Metyrosine capsules are not recommended for the control of essential hypertension.

Criteria

Brand Demser, generic metyrosine

For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

Prior Authorization

Length of Approval: 1 Time(s)
For diagnosis of Preoperative preparation

• Diagnosis of pheochromocytoma confirmed by one of the following biochemical testing:
• plasma free metanephrines
• urinary fractioned metanephrines
AND
• Medication is being used for preoperative preparation
AND
• Trial and failure, contraindication, or intolerance to both of the following:
• alpha-adrenergic blocker (e.g., phenoxybenzamine, doxazosin, terazosin)
• beta-adrenergic blocker (e.g., propranolol, metoprolol)
AND
• Prescribed by or in consultation with one of the following:
• Endocrinologist
• Endocrine surgeon

Brand Demser, generic metyrosine

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Treatment of pheochromocytoma

• Diagnosis of pheochromocytoma confirmed by one of the following biochemical testing:
• plasma free metanephrines
• urinary fractioned metanephrines
AND
• Patient with hormonally active (catecholamine excess) pheochromocytoma
AND
• One of the following:
• Patient is not a candidate for surgery
OR
• Chronic treatment due to malignant pheochromocytoma
AND
• Patient has not reached normotension after treatment with a selective alpha-1-adrenergic blocker (e.g., doxazosin, terazosin) and beta-adrenergic blocker (e.g., propranolol, metoprolol)
AND
• Medication will not be used to control essential hypertension
AND
• Prescribed by or in consultation with one of the following:
• Endocrinologist
• Provider who specializes in the management of pheochromocytoma

Brand Demser, generic metyrosine

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Treatment of pheochromocytoma

• Patient demonstrates positive clinical response to therapy (e.g., decreased frequency and severity of hypertensive attacks)

P & T Revisions

1970-01-01, 2025-12-18, 2025-02-14, 2024-03-14, 2023-09-13, 2023-03-01, 2022-10-26, 2022-03-01

References

1. Metyrosine Prescribing Information. Amneal Pharmaceuticals LLC. Bridgewater, NJ. July 2021.
2. Naruse M, Satoh F, Tanabe A, et al. Efficacy and safety of metyrosine in pheochromocytoma/paraganglioma: a multi-center trial in Japan. Endocrine Journal. 2018;65(3):359-371.
3. 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.

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Revision History

• 1970-01-01: No criteria change, bulk copy oRX-EHB
• 2025-12-18: no criteria changes, added IL statute operational note
• 2025-02-14: 2025 Annual Review - no changes
• 2024-03-14: 2024 Annual Review - no changes
• 2023-09-13: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-03-01: 2023 Annual Review - no changes
• 2022-10-26: Attached EHB Formulary
• 2022-03-01: New Program

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