droxidopa — Medical Mutual

Initial criteria

• Patient is age > 18 years; AND
• Patient has been diagnosed with symptomatic nOH 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
• Northera has been prescribed by or in consultation with a cardiologist or a neurologist; AND
• Patient meets ONE of the following conditions:
• - Patient has tried midodrine and one of the following other medications for the treatment of neurogenic orthostatic hypotension (e.g., fludrocortisone, desmopressin, dihydroergotamine, indomethacin, pyridostigmine, erythropoietin); OR
• - Patient has a contraindication or intolerance to all of the medications listed above; 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
• If the request is for brand Northera, the patient has tried generic droxidopa AND the brand is being requested due to formulation differences in inactive ingredients [documentation required]

Reauthorization criteria

• Response to therapy is required for continuation of therapy

Approval duration

1 month