Skip to content
The Policy VaultThe Policy Vault

Northera — Blue Cross Blue Shield of Kansas

neurogenic orthostatic hypotension (nOH)

Preferred products

  • droxidopa

Initial criteria

  • The prescriber has assessed and adjusted any medications known to exacerbate orthostatic hypotension (e.g., diuretics, vasodilators, beta-blockers) AND
  • ONE of the following: (A) The patient has tried and had an inadequate response to midodrine OR (B) The patient has an intolerance or hypersensitivity to therapy with midodrine OR (C) The patient has an FDA labeled contraindication to midodrine OR (B) The patient has another FDA labeled indication for the requested agent and route of administration AND
  • If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication AND
  • If the request is for a brand agent with an available generic equivalent (Northera/droxidopa), then ONE of the following: (A) The patient has an intolerance or hypersensitivity to the generic equivalent not expected to occur with the brand OR (B) The patient has an FDA labeled contraindication to the generic equivalent not expected to occur with the brand OR (C) There is clinical support for use of the brand over the generic AND
  • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, neurologist), or has consulted with such a specialist AND
  • 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 AND
  • ONE of the following: (A) The patient has a diagnosis of neurogenic orthostatic hypotension (nOH) AND BOTH of the following: (1) The patient has had improvement in severity from baseline symptoms (dizziness, lightheadedness, feeling faint, or blacking out) AND (2) The patient had an increase in systolic blood pressure from baseline of at least 10 mmHg upon standing from a supine position OR (B) BOTH of the following: (1) The patient has another FDA labeled indication for the requested agent AND (2) The patient has had clinical benefit with the requested agent AND
  • If the request is for a brand agent with an available generic equivalent (Northera/droxidopa), then ONE of the following: (A) The patient has an intolerance or hypersensitivity to the generic equivalent not expected to occur with the brand OR (B) The patient has an FDA labeled contraindication to the generic equivalent not expected to occur with the brand OR (C) There is clinical support for the use of the brand over the generic AND
  • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, neurologist), or has consulted with such a specialist AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 1 month; renewal 3 months