Northera — Blue Cross Blue Shield of Alabama

Preferred products

• droxidopa

Initial criteria

• The patient has tried and had an inadequate response to midodrine OR the patient has an intolerance or hypersensitivity to midodrine OR the patient has an FDA labeled contraindication to midodrine OR the patient has another FDA labeled indication for the requested agent and route of administration
• If the patient has an FDA labeled indication, then ONE of the following: • The patient's age is within FDA labeling for the requested indication for the requested agent OR • There is support for using the requested agent for the patient's age for the requested indication
• If the request is for a brand agent with an available generic equivalent (Northera/droxidopa), then ONE of the following: • The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the brand agent OR • The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the brand agent OR • There is support for the use of the requested brand agent over the generic equivalent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, neurologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• ONE of the following: • The patient has a diagnosis of neurogenic orthostatic hypotension (nOH) AND BOTH of the following: – The patient has had improvement in severity from baseline symptoms (dizziness, lightheadedness, feeling faint, or feeling like the patient may black out) – The patient had an increase in systolic blood pressure from baseline of at least 10 mmHg upon standing from a supine position OR • BOTH of the following: – The patient has another FDA labeled indication for the requested agent – The patient has had clinical benefit with the requested agent
• If the request is for a brand agent with an available generic equivalent (Northera/droxidopa), then ONE of the following: • The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the brand agent OR • The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the brand agent OR • There is support for the use of the requested brand agent over the generic equivalent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, neurologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 1 month, reauth 3 months