Welcome to the NORTHERA Commercial Copay Assistance Program

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Terms and Conditions for the Northera Commercial Copay Assistance Program


Terms and Conditions: Only commercially insured patients age 17 and older whose insurance policy provides coverage for Northera® (droxidopa) and who are not reimbursed for the entire cost of the prescription are eligible for the copay assistance (the “Offer”). Patients are not eligible for the Offer if they are self-pay or if the prescription is eligible to be reimbursed, in whole or in part, by any state or federal health care programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, or TRICARE. In addition, patients may not use the Offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.

The Offer is valid only for use with a valid prescription for Northera at the time the prescription is filled by the pharmacist and dispensed to the patient. The Offer applies only to prescriptions filled before the program expires or terminates. The copay prescriptions shall not be submitted for reimbursement to any public third-party payer, including Medicaid or Medicare, or any other similar federal or state healthcare program. Patients are responsible for complying with any obligations or requirements imposed by their insurance plans.

The Offer is not transferable. The selling, purchasing, trading, or counterfeiting of the Offer is prohibited by law. The Offer has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription.

Lundbeck reserves the right to rescind, revoke, terminate or amend the Offer without notice. The Offer is intended to comply with all applicable laws and regulations, including, without limitation, the federal Anti-Kickback Statute, its implementing regulations, and related guidance interpreting the federal Anti-Kickback Statute. The Offer is not health insurance. The Offer is valid only in the USA where allowed by law. There is no future purchase requirement associated with the Offer. Patient questions and requests to discontinue participation in the program can be directed to 1-844-601-0101 (8:00 am-8:00 pm ET, Monday through Friday).

Eligible commercially insured patients age 17 and older with a valid Northera prescription may participate in this program. Patients must pay at least $10 for each 30-day prescription. A maximum benefit limit may also apply. If the patient's total out-of-pocket pharmacy bill exceeds the cap established by Lundbeck, the patient will be responsible for the additional balance. Patients should confirm their out-of-pocket cost with their pharmacy at the time the pharmacy calls to dispense the prescription. By participating in the Copay Assistance program, the patient acknowledges and agrees that he/she is eligible to participate and that he/she understands and agrees to comply with the General and Copay Assistance Terms and Conditions.


To the Pharmacist:

USE AND IMPORTANT SAFETY INFORMATION

Use

NORTHERA (droxidopa) is a prescription medication used to reduce dizziness, lightheadedness, or the "feeling that you are about to black out" in adults who experience a significant drop in blood pressure when changing positions or standing (called symptomatic neurogenic orthostatic hypotension (nOH)) and who have one of the following:

  • - Parkinson's disease (PD), a neurodegenerative disease that causes slowness in muscle movement as well as shaking in the hands
  • - Multiple system atrophy (MSA), a Parkinson's-like disorder with more widespread effects on the brain and body
  • - Pure autonomic failure (PAF), a neurodegenerative disease that results in frequent drops in blood pressure upon standing
  • - Dopamine beta-hydroxylase deficiency, a condition where the body cannot make enough of the hormones that help regulate blood pressure
  • - Non-diabetic autonomic neuropathy, an inability to maintain blood pressure upon standing that can be caused by a number of rare diseases

Effectiveness beyond 2 weeks of treatment has not been established, and your doctor will decide if you should continue taking NORTHERA.

Important Safety Information

WARNING: SUPINE HYPERTENSION (this is high blood pressure while lying down)

When lying down, elevating the head and upper body lowers the risk of high blood pressure. Check your blood pressure in this position prior to starting and during NORTHERA treatment. If you experience high blood pressure, talk to your doctor about your NORTHERA treatment.

  • Do not take NORTHERA if you have a known allergy to NORTHERA or its ingredients.
  • NORTHERA may cause high blood pressure when lying down, which could lead to strokes, heart attacks, and death. To reduce this risk of supine hypertension, take your late afternoon dose of NORTHERA at least 3 hours before going to bed.
  • Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening side effect reported with NORTHERA. Call your doctor right away and go to the nearest emergency room if you develop these signs and symptoms: high fever, stiff muscles, movements that you cannot control, confusion or problems thinking, very fast or uneven heartbeats, or increased sweating. NORTHERA should be stopped immediately if NMS is diagnosed.
  • If you have coronary artery disease, irregular heartbeat, or heart failure, NORTHERA may worsen the symptoms of these disorders. Call your doctor if your symptoms become worse.
  • NORTHERA may cause allergic reactions. Stop taking NORTHERA and contact your doctor right away, or go to the nearest emergency room if you experience any signs or symptoms of an allergic reaction such as: fast heartbeat, nausea, vomiting, swelling, trouble breathing, hives, or rash. NORTHERA contains tartrazine (FD&C Yellow No. 5), which may also cause an allergic reaction, especially if you have had a reaction to aspirin.
  • The most common side effects with NORTHERA are headache, dizziness, nausea, and high blood pressure.
  • Taking NORTHERA with other medications may cause side effects. Tell your doctor if you take prescription or over-the-counter medicines, vitamins, or herbal supplements.
  • You should not breastfeed during treatment with NORTHERA.
  • If you plan to become or are currently pregnant, talk to your doctor as it is not known if NORTHERA could harm your unborn baby.
  • Take NORTHERA the same way each time, either with or without food.
  • If you miss a dose of NORTHERA, take your next dose at the regularly scheduled time. Do not double the dose.

For more information, please see the full Prescribing Information, including Boxed Warning for supine hypertension or go to www.NORTHERA.com.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.



USE AND IMPORTANT SAFETY INFORMATION
EXPAND

Use

NORTHERA (droxidopa) is a prescription medication used to reduce dizziness, lightheadedness, or the "feeling that you are about to black out" in adults who experience a significant drop in blood pressure when changing positions or standing (called symptomatic neurogenic orthostatic hypotension (nOH)) and who have one of the following:

  • - Parkinson's disease (PD), a neurodegenerative disease that causes slowness in muscle movement as well as shaking in the hands
  • - Multiple system atrophy (MSA), a Parkinson's-like disorder with more widespread effects on the brain and body
  • - Pure autonomic failure (PAF), a neurodegenerative disease that results in frequent drops in blood pressure upon standing
  • - Dopamine beta-hydroxylase deficiency, a condition where the body cannot make enough of the hormones that help regulate blood pressure
  • - Non-diabetic autonomic neuropathy, an inability to maintain blood pressure upon standing that can be caused by a number of rare diseases

Effectiveness beyond 2 weeks of treatment has not been established, and your doctor will decide if you should continue taking NORTHERA.

Important Safety Information

WARNING: SUPINE HYPERTENSION (this is high blood pressure while lying down)

When lying down, elevating the head and upper body lowers the risk of high blood pressure. Check your blood pressure in this position prior to starting and during NORTHERA treatment. If you experience high blood pressure, talk to your doctor about your NORTHERA treatment.