- Step Therapy Applies
- Prior Authorization: Neurogenic Orthostatic Hypotension:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 14 Day(s)
Reauthorization Required: Yes
- Neurogenic Orthostatic Hypotension:
Age Requirement: >= 18
Duration: 14 Day(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Clinical Evaluation of Current Medications: No
Baseline Blood Pressure Reading: No
Diagnostic Evaluation: No
Diagnosis Requirement(s): 1 of Dopamine Beta-Hydroxylase deficiency;Non-Diabetic Autonomic Neuropathy;Primary Autonomic Failure (Parkinson's, Multisystem Atrophy and Pure Autonomic Failure)
Reauthorization Requirement(s): 2 of Meet initial criteria;Symptom improvement for continuation of therapy
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