Samsca (tolvaptan tablets - Otsuka, generic) — Cigna

Hyponatremia

Initial criteria

Patient is age ≥ 18 years; AND
Patient meets ONE of the following criteria (a, b, or c):
a) Patient has a serum sodium < 125 mEq/L at baseline; OR
b) Patient meets BOTH of the following criteria: (1) Patient has less marked hyponatremia, defined as serum sodium < 135 mEq/L at baseline; AND (2) Patient has symptomatic hyponatremia (e.g., nausea, vomiting, headache, lethargy, confusion); OR
c) Patient has already been started on tolvaptan and has received < 30 days of therapy

Patient has been established on therapy for at least 30 days; AND
Patient meets at least ONE of the following (a or b):
a) According to the prescriber, the serum sodium level has increased from baseline (prior to initiating the requested drug); OR
b) According to the prescriber, patient experienced improvement in at least one symptom, such as nausea, vomiting, headache, lethargy, or confusion

Initial: 30 days; Renewal: 3 months