Northera (droxidopa capsules – Lundbeck, generic) — Cigna

Initial criteria

• Patient age > 18 years; AND
• Patient has been diagnosed with symptomatic neurogenic orthostatic hypotension due to primary autonomic failure (Parkinson’s disease, multiple system atrophy, and pure autonomic failure), dopamine beta-hydroxylase deficiency, or non-diabetic autonomic neuropathy; AND
• Patient has tried two other medications for the treatment of neurogenic orthostatic hypotension (examples include atomoxetine, dihydroergotamine, fludrocortisone, indomethacin, midodrine, or pyridostigmine); AND
• Patient has initiated non-pharmacological measures including but not limited to elevation of the head of the bed, orthostatic compression garments, and appropriate physical training; AND
• Medication has been prescribed by or in consultation with a cardiologist or a neurologist.

Approval duration

1 year