- Quantity Limit: limit maximum 600 mL PER 30 day(s)
- 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
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