droxidopa — Blue Cross Blue Shield of Alabama

Initial criteria

• Patient has a diagnosis of neurogenic orthostatic hypotension (nOH) AND ALL of the following:
• • Prescriber has performed baseline (prior to therapy) blood pressure readings while the patient is sitting or supine AND within 3 minutes of standing from a supine position
• • Patient has a decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg diastolic blood pressure within 3 minutes after standing
• • Patient has persistent and consistent symptoms of nOH caused by ONE of the following: – Primary autonomic failure (Parkinson's disease, multiple system atrophy, or pure autonomic failure) – Dopamine beta-hydroxylase deficiency – Non-diabetic autonomic neuropathy
• • Prescriber has assessed severity of baseline symptoms of dizziness, lightheadedness, feeling faint, or feeling like the patient may black out
• • Prescriber has assessed and adjusted, if applicable, any medications known to exacerbate orthostatic hypotension (e.g., diuretics, vasodilators, beta-blockers)