droxidopa — CareFirst (Caremark)

Initial criteria

• Member has a persistent, consistent decrease in systolic blood pressure of at least 20 mmHg or decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing or head-up tilt test
• Member has neurogenic orthostatic hypotension due to any of the following diagnoses: primary autonomic failure due to Parkinson’s disease, multiple system atrophy, or pure autonomic failure; dopamine beta hydroxylase deficiency; or non-diabetic autonomic neuropathy

Reauthorization criteria

• Member has experienced a sustained decrease in symptoms of neurogenic orthostatic hypotension (e.g., dizziness, lightheadedness, 'feeling that you are about to black out')
• Member has neurogenic orthostatic hypotension due to any of the following diagnoses: primary autonomic failure due to Parkinson’s disease, multiple system atrophy, or pure autonomic failure; dopamine beta hydroxylase deficiency; or non-diabetic autonomic neuropathy

Approval duration

Initial: 3 months; Reauthorization: 12 months