tolvaptan — Blue Cross Blue Shield of Alabama

Initial criteria

• Requested agent was initiated (or re-initiated) in the hospital
• Prior to initiating the requested agent, the patient has/had a diagnosis of clinically significant hypervolemic or euvolemic hyponatremia defined by ONE of the following: • Serum sodium less than 125 mEq/L OR • Serum sodium ≥125 mEq/L and symptomatic hyponatremia that has resisted correction with fluid restriction
• Patient does NOT have underlying liver disease, including cirrhosis
• Medications known to cause hyponatremia (antidepressants, anticonvulsants, antipsychotics, anticancer, antidiabetic, vasopressin analogues, miscellaneous) have been evaluated and discontinued when appropriate
• Requested agent will NOT be used in combination with another tolvaptan agent for the requested indication
• Patient does not have any FDA labeled contraindications to the requested agent
• Patient has not already received 30 days of therapy with the requested agent for the current hospitalization

Approval duration

365 days