tolvaptan — Highmark

Preferred products

• tolvaptan

Initial criteria

• age ≥ 18 years
• diagnosis of clinically significant hypervolemic or euvolemic hyponatremia
• documentation of serum sodium < 125 mEq/L OR documentation of serum sodium < 135 mEq/L with symptoms (e.g., nausea, malaise, lethargy, headache, seizures)
• prescriber attests that member has resisted correction with fluid restriction
• prescriber attests that member has been initiated or re-initiated on Samsca therapy in a hospital setting
• if request is for brand Samsca, member has experienced therapeutic failure or intolerance to generic tolvaptan

Reauthorization criteria

• diagnosis of a new episode of clinically significant hypervolemic or euvolemic hyponatremia
• documentation of serum sodium < 125 mEq/L OR documentation of serum sodium < 135 mEq/L with symptoms (e.g., nausea, malaise, lethargy, headache, seizures)
• prescriber attests that member has resisted correction with fluid restriction
• prescriber attests that member has been initiated or re-initiated on Samsca therapy in a hospital setting
• if request is for brand Samsca, member has experienced therapeutic failure or intolerance to generic tolvaptan

Approval duration

1 month