Skip to content
The Policy VaultThe Policy Vault

Nocdurna (desmopressin acetate sublingual tab) — Blue Cross Blue Shield of Alabama

nocturia due to nocturnal polyuria

Preferred products

  • generic oral desmopressin

Initial criteria

  • - The patient has a diagnosis of nocturnal polyuria confirmed by a 24-hour urine collection AND
  • - The requested agent will be used to treat nocturia due to nocturnal polyuria AND
  • - The patient's serum sodium concentration is within normal range [135–145 mEq/L or within testing laboratory’s normal range] AND
  • - The patient has tried and had an inadequate response to behavior modifications for nocturia (e.g., physician-monitored restriction of fluids, afternoon naps, elevation of legs, compression stockings) AND
  • - ONE of the following: the patient’s age is within FDA labeling for the requested indication OR the prescriber has provided information in support of off-label age use AND
  • - ONE of the following: the patient has tried and had an inadequate response to generic oral desmopressin OR has an intolerance or hypersensitivity to oral desmopressin not expected with requested agent OR has an FDA labeled contraindication to oral desmopressin not expected with requested agent AND
  • - The patient will NOT be using the requested agent in combination with a loop diuretic AND
  • - The patient will NOT be using the requested agent in combination with systemic or inhaled glucocorticoids AND
  • - The patient is NOT pregnant AND
  • - The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • - The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • - The patient has had clinical benefit with the requested agent AND
  • - The patient's serum sodium concentration is within normal range [135–145 mEq/L or within testing laboratory’s normal range] AND
  • - The patient will NOT be using the requested agent in combination with a loop diuretic AND
  • - The patient will NOT be using the requested agent in combination with systemic or inhaled glucocorticoids AND
  • - The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months