Northera — Highmark

Preferred products

• midodrine
• fludrocortisone

Initial criteria

• age ≥ 18 years
• Diagnosis of neurogenic orthostatic hypotension (nOH) substantiated by BOTH of the following:
• 1. Documented decrease of ≥ 20 mmHg in systolic blood pressure within 3 minutes of standing OR decrease of ≥ 10 mmHg in diastolic blood pressure within 3 minutes of standing
• 2. At least one symptom of nOH upon standing: dizziness, lightheadedness, feeling faint, or feeling likely to black out
• Cause of nOH is ONE of the following: primary autonomic failure (e.g., Parkinson’s disease, multiple system atrophy, or pure autonomic failure) OR dopamine beta-hydroxylase deficiency OR non-diabetic autonomic neuropathy
• Therapeutic failure, intolerance, or contraindication to ONE of the following preferred products: midodrine OR fludrocortisone
• If requesting brand Northera, therapeutic failure or intolerance to generic droxidopa

Reauthorization criteria

• Member has experienced an increase in systolic or diastolic blood pressure upon standing from baseline OR a decrease from baseline in at least one symptom of nOH upon standing (dizziness, lightheadedness, feeling faint, or feeling likely to black out)
• If requesting brand Northera, therapeutic failure or intolerance to generic droxidopa

Approval duration

initial: up to 4 weeks; reauthorization: up to 3 months