tolvaptan — Blue Cross Blue Shield of Kansas

clinically significant hypervolemic hyponatremia

Initial criteria

Requested agent was initiated (or re-initiated) in the hospital AND
Prior to initiating therapy, patient has/had clinically significant hypervolemic or euvolemic hyponatremia defined by ONE of the following: (A) serum sodium <125 mEq/L OR (B) serum sodium ≥125 mEq/L and symptomatic hyponatremia that has resisted correction with fluid restriction AND
Patient does NOT have underlying liver disease, including cirrhosis AND
Medications known to cause hyponatremia have been evaluated and discontinued when appropriate AND
Patient will NOT be using the requested agent in combination with another tolvaptan product for the requested indication AND
Patient does not have any FDA labeled contraindications to the requested agent AND
Patient has not already received 30 days of therapy with the requested agent for the current hospitalization

365 days