Delfampridine (Ampyra)

Self administration- Oral

Indications for Prior Authorization

  • indicated to improve walking in patients with multiple sclerosis (MS).

Patients must meet the following criteria for the indications above.

  • Diagnosis of MS confirmed by a neurologist


  • Creatinine clearance > 50 ml/min Ampyra is contraindicated in moderate - severe renal impairment.


  • An EDSS score of <seven (patient must be ambulatory) Ampyra is contraindicated in patients with a history of seizure.

Seizures in patients taking Ampyra should be reported to Acorda drug safety at 1-800-367-5109 or the FDA (1-800-332-1088).

All coverage requests must include the results of two walking studies as baseline data.

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee.

  • All non-FDA approved indications


Ampyra 10 mg PO every 12 hours

Use of doses higher than 10 mg twice a day may increase the risk of seizure.


Ampyra therapy will be approved initially for a three month trial.

Renewal requires chart note documentation of improvement in the patient's walking parameters such as distance and speed.

Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: November 2010 Reviewed: July 2011 Reviewed: Dr. John Schafer