Dalfampridine (Ampyra)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Improves walking speed in patients with multiple sclerosis (MS)

Patients must meet the following criteria for the indication(s) above:

  • Prescribed by a neurologist or MS specialist, AND

  • Patient must have completed a timed 25-foot walking test and scored between 8-45 seconds (updated 25-foot walking test is required for each review), AND

  • Dose does not exceed 20mg per day

This Medication is Not Approvable for the following condition(s):

  • Any condition not listed above does not meet WHA criteria for approval

Dosing:

  • Adults: 10 mg orally every 12 hours (maximum daily dose: 20mg)

  • Missed doses: do not administer double or extra doses if a dose is missed

Approval:

  • Inital approval is 3 months

  • Renewal after three months: for 12 months if patient has achieved at least a 20% improvement from baseline in the timed 25-foot walking test
  • Yearly renewals: for 12 months if patient maintains 20% improvement from baseline in the timed 25-foot walking test
  • All approvals limited to a 30 day supply per fill

 

Last review date: March 7, 2017