COVERED USES:

FDA Approved Indications:

Central Diabetes Insipidus

Primary Nocturnal Enuresis (Tablets only)

All FDA-approved indications not otherwise excluded from part D.

AGE RESTRICTIONS:

Primary Nocturnal Enuresis: Children six (6) years and older may be covered.

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

Diagnosis of central diabetes insipidus or primary nocturnal enuresis.

Re authorization for primary nocturnal enuresis requires documentation of failure of two behavioral techniques (examples include motivational therapy, bladder training, fluid management, and alarm clocks).

EXCLUSION CRITERIA:

• Intranasal formulations are not indicated for treatment of primary nocturnal enuresis.
• History of or existing hyponatremia, moderate to severe renal insufficiency (creatinine clearance less than 50 ml/min)

COVERAGE DURATION:

Diabetes insipidus - up to 1 year. Primary nocturnal enuresis - up to 2 months.