- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- PA Applies
- Quantity Limit: 6 capsules per 1 day(s).
- Step Therapy: Neurogenic Orthostatic Hypotension:
ST Multiple Generics
- Neurogenic Orthostatic Hypotension:
Age Requirement: >= 18
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(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;Orthostatic Hypotension;Primary Autonomic Failure (Parkinson's, Multisystem Atrophy and Pure Autonomic Failure)
Reauthorization Requirement(s): 1 of Decrease in dizziness;Positive response to therapy
- Prior Authorization: Neurogenic Orthostatic Hypotension:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
Reauthorization Required: Yes
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