droxidopa — Blue Cross Blue Shield of Kansas

Initial criteria

• 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 in diastolic blood pressure within three minutes after standing
• Patient has persistent and consistent symptoms of neurogenic orthostatic hypotension (nOH) caused by one of the following: primary autonomic failure (Parkinson's disease, multiple system atrophy, or pure autonomic failure) OR dopamine beta-hydroxylase deficiency OR non-diabetic autonomic neuropathy
• Prescriber has assessed the severity of the patient’s baseline (prior to therapy) symptoms of dizziness, lightheadedness, feeling faint, or feeling like the patient may black out