Prior Authorization Criteria for Approval

Initial evaluation

Droxidopa will be approved when ALL of the following are met:

1. The patient has a diagnosis of neurogenic orthostatic hypotension (nOH)
   AND
2. The prescriber has performed baseline blood pressure readings while the patient is sitting or supine (lying face up), AND also within three minutes of standing from a supine position
   AND
3. The patient has a decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg diastolic blood pressure within three minutes after standing
   AND
4. The patient has persistent and consistent symptoms of neurogenic orthostatic hypotension (nOH) caused by ONE of the following:
   1. Primary autonomic failure [Parkinson's disease (PD), multiple system atrophy, or pure autonomic failure]
      OR
   2. Dopamine beta-hydroxylase deficiency
      OR
   3. Non-diabetic autonomic neuropathy
      AND
5. The prescriber has assessed the severity of the patient’s baseline symptoms of dizziness, lightheadedness, feeling faint, or feeling like the patient may black out
   AND
6. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
   AND
7. The requested dose is within FDA labeled dosing for the requested indication

Length of Approval: 1 month

Renewal Evaluation

Droxidopa will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND
2. The patient has a diagnosis of neurogenic orthostatic hypotension (nOH)
   AND
3. The patient has had improvements or stabilization with the requested medication as indicated by improvement in severity from baseline symptoms of ONE of the following:
   1. Dizziness
   2. Lightheadedness
   3. Feeling faint
   4. Feeling like the patient may black out
      AND
4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
   AND
5. The requested dose is within FDA labeled dosing for the requested indication

Length of Approval: 3 months