COVERED USES:

FDA Approved Indications:

DDAVP

• Central Diabetes Insipidus
• Primary Nocturnal Enuresis (Tablets only)

Requests for a non-FDA approved (off-label) indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

AGE RESTRICTIONS:

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

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:

Central Cranial Diabetes Insipidus: Antiduretic replacement therapy in the management of central diabetes insipidus for the management of the temporary polyuria and polydipsia following head trauma or surgery in the pituitary region. Covered/no limit.

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:

Initial authorization for Primary nocturnal enuresis is 2 months.